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Name(Required)

Location(Required)

Date of incident(Required)

Time of incident

Are you reporting a:(Required)

ACCIDENT

INCIDENT

NEAR MISS

Describe the incident with detail.

You could use the microphone on your keyboard

How bad could it have been?

Very Serious

Serious

Minor

What are the chances of it happening again?

Minor

Occasional

Rare

Did anyone witness the incident?

Yes

No

File upload (optional)

INCIDENT REPORT