Incident Report Form

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Incident Report


Personal information














Name of person reported to (fill out all that apply)














Hierarchy of control
1. Elimination
2. Substitution (use an alternative)
3. Isolate (separation from hazard)
4. Redesign (change equip/process)
5. Administration (change work practice)
6. Personal protective equipment (gloves, glasses, hearing protection)



Supervisor/instructor signature and report date



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