(or more) Witness Supervisor Name Describe the incident Date of Incident Time of the incident Location of the Incident (Address) Specific Location of the incident (e.g office, mechanical room, shop) Did the incident involve property damage Affected body Part: Yes No Head/face Eye Neck/shoulder Fingers Chest/lower trunk Other Arms/elbow Hip Shift Was a motor vehicle involved in this incident Right Hand Back Left Hand Leg/knee 1st 2nd 3rd Yes No Wrist/Head Foot/ankle Rib Toes Describe, step-by-step, how the incident occurred: What would you recommend to prevent this accident from recurring: Witness Signature Date Page 1 of 1.
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