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Incident Reporting
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Your report has been submitted.
Your Name:
(required)
Your Email:
(required)
Your Phone Number:
What date and time did incident occur?
(required)
Where did incident occur?
(required)
Who was injured?
(required)
Was there equipment involved the accident? (if so please specify)
What was the involved party doing at the time of the incident?
(required)
Where was the involved party at the time of the incident?
(required)
What was the involved party doing immediately prior to the incident?
Who witnessed the incident?
(required)
Where were the witnesses?
(required)
Where was the supervisor? (if applicable)
(required)
Who first responded after incident occurred?
(required)
How long was the involved party performing volunteer tasks / job duties? (If applicable)
What shift hours did the volunteer / staff work that day?
Was PPE (personal protective equipment) required for the tasks on which the incident occurred?
(required)
If PPE was required, exactly what kind of PPE was required?
Was the involved party wearing the required/appropriate PPE?
Could the PPE in any way have been a contributing factor to the occurrence of the incident / injury?
Thank you for your submission. Based upon the information collected in the investigation, the root cause(s) of the incident will be determined, and recommendations for prevention will address the root cause(s).
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