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DEPARTMENT PHONE # <br /> Injury Incident Property Damage <br /> <br />1.EMPLOYEE (last name, first name, mi)2.EMPLOYEE ID No.3.SEX <br /> M F <br />4.AGE 5.DATE/TIME OF INCIDENT <br />6.TIME IN JOB <br /> Less than 1 mo. 6 mos. to 1 year <br /> 1 to 5 mos. More than 1 year <br />7.JOB TITLE AT TIME OF ACCIDENT 8.EMPLOYMENT CATEGORY <br />Full-time Temporary <br /> Part-time Student <br />9.SPECIFIC LOCATION OF NEAR LOSS(bldg., floor, room #, outside) 10. WITNESS (list name(s) & phone #) <br /> 11.DESCRIPTION OF NEAR LOSS (Describe sequence of events, including time, date, and location of incident. Attach photos, drawings, or separate page if necessary) <br />12.FACTORS (Why it Happened) Describe conditions or practices, if any, that may have led to the occurrence of this incident. Attach separate page if necessary <br />13.CORRECTIVE ACTIONS (Prevention). Developed jointly with H&S <br />14.REPORTED BY <br />____________________________________________ ________________________ <br />Signature Date <br />___________________________________________________________________________ <br />15.HEALTH & SAFETY DIRECTOR COMMENTS. <br />_________________________________________________________________________ <br />_________________________________________________________________________ <br />______________________________________________ ________________________ <br />Signature Date <br />16.HUMAN RESOURCES REVIEW <br />_________________________________________________________________________ <br />_________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />____________________________________________ ________________________ <br />Signature Date <br />INCIDENT <br /> REPORTING FORM <br />Page 1 of 2