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Safety Incident Reporting Form
First name
Last name
Telephone
E-mail
Company
Date of incident
Time of incident
Describe the incident or dangerous situation
Measures to be taken
Specific details
(Near) Accident Report
First name
Last name
Telephone
E-mail
Company
Name of victim
Location
Department
Date of accident
Time of accident
Injury to:
-Please make a selection-
No injury
Head
Eye
Arm
Hand
Leg
Foot
Upper body
Extensive
Severity of injury
-Please make a selection-
Minor
Major
Death
Assistance provided by
-Please make a selection-
Employee
First aid-er
Ambulance
Hospital
Fire brigade
Security
Calamity team
How did the accident happen (please provide details)
Describe any damage to property of belongings
Security Incident Reporting Form
First Name
Last Name
Telephone
E-mail
Company
Date of incident
Time of incident
Describe the incident or dangerous situation:
Measures to be taken:
Specific details:
Submit
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