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Incident Date:
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Time of Incident:
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Witness:
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Client:
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Project:
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INCIDENT TYPE:
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INJURY / ILLNESS
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Experience:
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Nature of Injury:
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PROPERTY DAMAGE
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Description of Property:
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Estimated Cost:
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Other Actual / Potential Loss:
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Risk Potential if Not Corrected:
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A. Loss severity potential
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Minor
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B. Probable Recurrence Rate:
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Incident Description:
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Diagram of Scene:
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Witness(es):
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Witness(es) Statement Attached:
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Immediate cause(s):
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Description:
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Underlying cause:
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Description:
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Corrective Action(s):
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Date Report Completed:
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