Employee Incident Report

PLEASE NOTE THIS FORM MUST BE COMPLETED WITHIN ONE HOUR OF INCIDENT OCCURING AND MUST BE SUBMITTED TO SUPERVISOR OR DIRECTOR WITHIN 24 HOURS OF INCIDENT

Please correct the errors described below.

IF THE INCIDENT WAS SEVERE, PLEASE TAKE PHOTOS OF THE INJURY SITE AND THE CAUSE OF THE INJURY AND ATTACH THEM TO THIS REPORT

By signing below, I confirm that all of the information provided here and on any attachments are complete and true to the best of my knowledge.

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