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PCC Incident Reports 2022
This form is to capture information regarding any unsafe incidents at PCC HQ or on-site.
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* Indicates required question
Email
*
Your email
Name person submitting this form.
*
Your answer
Worksite/Location Of Incident
*
Your answer
Date Of Incident
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MM
/
DD
/
YYYY
Time Of The Incident
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Time
:
AM
PM
Location of incident on worksite
*
Your answer
Name of injured person(s)
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Your answer
Brief description of incident
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Your answer
Work / activity undertaken at time of incident (identify any plant, substance, equipment involved)
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Your answer
Description of injuries sustained.
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Your answer
Person(s) who saw the incident or was first at the scene
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Your answer
Action taken (if any) to prevent reoccurrence of incident
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Your answer
Please list any Safety officers, site managers or supervisors that were present on the worksite during the incident
*
Your answer
A copy of your responses will be emailed to the address you provided.
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