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About Us
Who We Are
Mission
Our Team
Our Services
Residences
Careers
Staff Portal
Resident Portal
Contact Us
Accident, Injury or Near Miss Report
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Accident, Injury or Near Miss Report
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Employee Name
*
First
Last
Date / Time of Event
*
Date
Time
I am reporting a work-related:
*
Injury
Accident
Near Miss
Job Title:
*
Supervisor Name
*
Has your supervisor been made aware of this incident?
*
Yes
No
Location of Incident
*
Witnesses:
*
Incident Description (Describe tasks being performed and sequence of events)
*
What could have been done prevent this injury/near miss?
*
What parts of your body were injured? If a near miss, how could you have been hurt?
*
Was medical treatment necessary?
*
Yes
No
If yes, name of hospital/physician:
*
Date / Time of Medical Care
*
Date
Time
Has this part of your body been injured before?
*
Yes
No
If yes, when?
*
Do you have other employment?
*
Yes
No
Company Name:
*
Any other relevant information:
Submit
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