Clone of Clone of Clone of Incident/Hazard Report

Clone of Clone of Clone of Incident/Hazard Report

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  • TYPE OF REPORT (Select All That Apply)

  • ***Contact _______________________ as soon as possible after any serious event or if you have questions about reporting or actions that need to be taken after incident. All injuries that occur to temporary employees must be immediately reported to the appropriate temp agency. The agency will determine where to send the employee for outside treatment, if needed.

    • Notification & Contact Info  
    • MEDICAL PROVIDER & TRANSPORTATION INFO:

    • CONTRACT AGENCY NOTIFICATION:

       

       

    • Associate Name  
    • Associate Information  
    •  -  - Pick a Date
    •  -
    •  -  - Pick a Date
    • Incident/Hazard Reporting  
    •  -  -
      at
       :
      Pick a Date
    •  -  -
      at
       :
      Pick a Date
    • Incident Details  
    • Property Damage  
    • Chemical Spill/Release Info  
    • Business Interruption  
    • Injury Details  
    • Incident Causes  
    • Contributing Factors  
    • Medical Response  
    • Incident Response  
    • Drug/Alcohol Testing  
    • Corrective/Preventive Actions  
    • Photos & Other Evidence  
    • Upload a File
    • Upload a File
    • Upload a File
    • Witnesses (do a supplemental statement for each witness if more than one)  
    • Employee Statement (if not available, do a supplemental statement when employee is available)  
    • Supervisor Submission  
    •  
    • Should be Empty: