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Case No.
Employee Name (Optional)
Establishment name
Conducted on
Job title
Date of injury or onset of illness
Where the event occurred
Type of incident
Describe injury or illness, parts of body affected, and object/substance that directly injured or made person ill.
Upload photos of incident
Classify the case. Check only one box for each case based on the most serious outcome for that case:
Observations and comments
Full Name and Signature of Record Keeper