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INCIDENT REPORT
Your name
Date of incident
Time of incident
Select Site
Select site:
NM or INC or ACC
*
NEAR MISS
INCIDENT
ACCIDENT
What happened?
Was 1st aid given?
Yes
No
N/A
Who and what 1st aid was given
Does worksafe need to be notified?
Yes
No
N/A
BODY PART INJURED
(if hurt)
HEAD
LEG
FOOT
HAND
ARM
KNEE
ELBOW
EYE
FINGER/S
CHEST
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