Incident Report (Employees)
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Employee Name *
Incident Location *
Date of Incident *
You MUST provide the exact date.
MM
/
DD
/
YYYY
Time of Incident *
Approximately what time did the incident occur?
When was the incident reported to the employer?
MM
/
DD
/
YYYY
Was anyone injured as a result of the incident? *
Please choose the most applicable response.
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