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Documenting Health and Safety 43 Health and safety incident report form 2 The affected person Worker other: (i.e., visitor, contractor) Name Address Date of birth Email—work: Email—home Employer’s name if other than worker Address Phone Witness details Names(s) and contact information Names(s) and contact information First aid First aid provided: Yes By whom: No N/A Time of attendance: Contact information: Details of provision: 44 Documenting Health and Safety Health and safety incident report form 3 Post incident Where did the person involved in the incident go next To the hospital home returned to work other Was a member of the joint health and safety committee notified of the incident Yes No Name: Additional notes: Documenting Health and Safety cope 343 45.
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