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Your Name*

Your Phone Number*

What number can you be reached at to discuss this report?

Injured Employee Name*

Location of Incident*

Incident Type*

Category*

Classification*

Body Part*

Cause*

LOTO Procedures Followed?*

Brief Description of Incident*

Standard Work Requirement*

Please state the company policy for the task performed when injured.

Actual Steps Taken by Employee*

Please describe what the employee did that was different from the above requirement.

Facility Impact*

Contributing / Casual Factors*

Proposed Corrective Actions*

Pictures if necessary

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