Location of Incident (eg: at home, at work, at the mall, etc.)
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Description of Incident (Who, What, Where, When)
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Injury - Describe Type and Location
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Body Part Injured
Immediate action to ensure health and welfare of Individual(s)
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Name of Primary Person(s) involved (PPIs)
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Relationship to Individual
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Witnesses to Individual
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Others Involved
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Type of Notification
NOTE: Please choose who else you have notified about this incident.
Name/Title and Date/Time of all persons notified:
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Reporter's Name and Phone Number
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Date Reporter Discovered the Incident
MM
/
DD
/
YYYY
Time Reporter Discovered the Incident
Time
:
AM
PM
Was Further Medical Follow-Up Provided? (If yes, please explain)
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Was Additional Administrative Action Given? (If yes, please explain)
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Causes and Contributing Factors
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Preventative Measures
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Signature (by entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.) *