Case Number

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Title/Name

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Incident Type

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Date/Time of Incident

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Incident Location

LocationPremisesChem StorageProjects Location

Location Address

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Specific Location Details

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Geo Location Address

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Latitude/Longitude

Person Involved

StaffContractorVisitor

Select Worker

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First Name

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Last Name

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Email Address

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Phone Number

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Other Information

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Description of Events

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Confidential ?

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Parties to notify is required

Consequence Ranking

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Potential Outcome

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Initial Notification Severity

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Injury Details

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Nature of Injury/Illness

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Body Parts Harmed

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Immediate Treatment Obtained

Ambulance treatment on siteDoctorFirst Aid
Health ServiceHospitalNone
Other

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Treatment Provided By

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Hazard(s) that caused incident

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Person Responsible

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First Reported By

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First Reported Date

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First Reported Contact Phone

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First Reported By Email

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First Reported To

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First Reported To Phone

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First Reported To Email

First Reported To Email is required

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