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Incident Report
Incident Report
AN Incident is a potential hazard due to unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment that have the potential to cause work related injuries and contribute to work related incidents. Please complete this form to report these Incident situations.
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Employee
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First
Last
Location
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Incident Date
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MM
DD
YYYY
Incident Time
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:
HH
MM
AM
PM
Please check all appropriate conditions:
*
Unsafe Act
Unsafe Condition
Unsafe Equipment
Unsafe use of Equipment
Describe the Incident
Causes: (primary & contributing)
Corrective Action Taken:
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Date
Date Format: MM slash DD slash YYYY
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Jefferson City, MO 65109
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