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WORKPLACE INJURY AND INCIDENT REPORT
Company:
Company Name:
Company Representative's Name:
Company Representative's Title:
Company Name:
| Company Address: |
, ,
Employee:
Employee's Name:
Company Name:
| Employee's Address: |
, ,
Date of Birth:
Date of Hire:
Incident Details:
Incident Case Number:
Date of Incident:
Time of Incident: Time cannot be determined
Employee's Workday Start Time:
Incident Investigation Date and Time:
Events Leading Up To the Incident:
Details of the Incident:
The Results of the Incident:
Objects or Substances involved in the incident:
Medical Treatment Required: was did
| Report Completed By: | _________________________________________ |
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