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Details
Company (Eg. Signet)
Department (Eg. Operations, Marketing, Finance)
Person Reporting the Incident
Supervisor Name
Date Reported
Time of Report
Date Occurred
Location
Area
Brief Description
Classification
Injury
Near Miss
Environment
Equipment / Property Damage
Production
Violence and Abuse
Community Complaint
Vehicle
Security
Other
Who was injured? (if applicable)
What part of the body did they injure? (if applicable)
What was done to treat the injury? (if applicable)
Confidentiality
Standard
Legal Privilege
Confidential
Details
Immediate/Temporary Controls
Witnesses
Attachment
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