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Accident Report

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caelaangelina
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3 views1 page

Accident Report

Uploaded by

caelaangelina
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Accident Report

The Incident
Reported by: Department:
Email: Phone:
Date of Occurrence: Time:
Exact Location:
Accident Incident Near miss Violence Health Safety
What happened? Report anything in detail that may have contributed to the incident (e.g. poor lighting,
negligence). Use additional paper as necessary and attach it to the form.

Describe the outcome: harm/ health effect/ damage.

Describe corrective measures taken to address immediate hazards related to the incident.

The Affected Person


Worker Others: i.e. visitor, contractor Name:
Address: Date of Birth:
Email (work): Email (home):
Employer's name if other than a worker: Address: Cotton Field Phone No:
Witness Details
Name (s) and contact information Name (s) and contact information

First Aid
By whom Yes No N/A Time of attendance

Details of Provision
Contact Information
Tom Evans
E-mail-

Witness signature: Date:

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