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Documenting Health and Safety
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Health and safety incident report form
The incident
Reported by Department
Email Phone Ext
Date of occurrence Time
Exact locaon
Accident
Incident Near miss Violence Ill health Safety
What happened? Report any details that may have contributed to the incident (i.e., poor lighng).
Use addional paper as necessary and aach to form.
Describe the outcome: harm/health eects/damage.
Describe correcve measures taken to address immediate hazards related to incident.