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Event Incident Report Form

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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.
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