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Accident Report Form
Thank you for reporting this accident. Please be as detailed as possible
9
Questions
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1
Your Name
First Name
Last Name
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2
Your Email
example@example.com
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3
Your Phone Number
Please enter a valid phone number.
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4
Location the Accident Occurred
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5
Name of the Affected Person
First Name
Last Name
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6
Description of the Incident
What happened Before and During the Accident?
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7
Follow-up
What happened after the Accident? How was the Accident Managed? I.e. was First Aid Provided?
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8
Details of Alleged Injury
How was the person affected?
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9
What Further Action May be Acceptable?
'I don't know' and 'none' are acceptable
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