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Accident/Injury Report
Date of Incident
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Time of Incident
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Reported By
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*
What type of accident was this?
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Where did the accident take place?
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Where did the accident take place?
DTK Scoop Shop
UPT Scoop Shop
Production Facility
During Delivery
Other
Injured Party
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Describe the accident/injury
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Was a manager or supervisor informed?
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Was a manager or supervisor informed?
Yes
No
Were the emergency services contacted?
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Were the emergency services contacted?
Yes
No
Was the employee taken to a hospital or medical facility?
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Was the employee taken to a hospital or medical facility?
Yes
No
List any equipment involved in the accident
Any photos of incident (max. 5)
Click to choose a file or drag here
Did the injured party lose any workdays because of the accident/incident?
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Did the injured party lose any workdays because of the accident/incident?
A
Yes
B
No
What do you recommend we do to prevent this in the future?
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Sign and Submit
Signature
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Signature
Submit