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Health & Safety Form
Name
Email
Select a date
Please answer the following questions:
Persons involved and if any injuries sustained:
Who needs to be contacted, who has been conducted when and by whom:
When and where did the incident, accident, or near miss occur:
Other descriptive details about the incident:
Names and contact details of any witnesses:
Controls that were in place and why they didn't work:
What treatment was provided:
Any actions that can be taken or changes made that would eliminate the possibility of a future similar incident:
Submit
Thank you. We have recieved your report.
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