Basic Information

• Incident ID: ___________________
• Date/Time of Incident: [//_____]
• Location of Incident: ______________________________
• Reported By: ______________________________________
• Date of Report: [//_____]

Incident Details

• Type of Incident (Injury, Near Miss, Property Damage, Environmental):

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• Description of the Incident:

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Personnel Involved

• Name: _____________________________________________

• Role: _____________________________________________

• Action Taken: ______________________________________

• Other Personnel Involved: ___________________________

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Witness Statements

• Name: _____________________________________________

• Statement:

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Immediate Actions Taken

• Action: ___________________________________________
• By Whom: __________________________________________