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Event Incident Report Form

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Event Incident Report Form

Audit

PERSONAL AND INCIDENT DETAILS

Full Name

Date of Birth

Sex

Occupation

Contact number

Home address

Email address

INJURY DETAILS

Type of injury or disease (e.g burn)

Part/s of the body affected

Date and time of occurrence

Was medical treatment given?

Treatment provided

Provider

Date and Time of treatment

How did the injury happen?

COMPLETION

Name and Signature

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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.