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Incident Investigation and Analysis Report

  1. EMPLOYEE'S REPORT OF INCIDENT

  2. Did employee receive medical attention:*

  3. if no witnesses please type "none"

  4. Was personal protective equipment required for performing this? *

  5. If Yes, was it used?*

  6. If Yes, was it used correctly ?

  7. SUPERVISOR/DEPARTMENT HEADS ACCOUNT OF INCIDENT:

  8. Incident was:

  9. Were blood or urine tests administered ?

  10. Were any Personnel Policies or Safety Policies violated ?

  11. Was personal protective equipment required for performing this ?

  12. If Yes, was it used?

  13. If Yes, was it used correctly?

  14. Any property damage:

  15. Any of the following need to be submitted?

    If yes select and submit them to Mark Mattick.

  16. Leave This Blank:

  17. This field is not part of the form submission.