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This form should be used to report any injury or property damage.
This form does not replace the Workers' Compensation form. Contact
in the case of an employee injury for Workers' Compensation information.
"A" Number (ex. A01234567)
Injury or Property Damage
Property Damage Only
Both Injury and Property Damage
Date of Incident
Location of Incident
Detailed Description of the Incident
Individuals Involved/Witnesses (how they were involved and contact information if known)
Cause of Incident (choose all that apply)
Deviation from Standard Operating Procedure
Lack of Standard Operating Procedure
Improper/lack of PPE (personal protective equipment)
Lack of training
Immediate Corrective Actions
Has the Workers' Compensation form been completed?
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