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Employee Name
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First Name
Last Name
DATE & TIME OF ACTUAL INCIDENT * (Please select both)
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Incident Type
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Safety Concern
Incident Report
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Accident
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Status
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Reported By
*
Adrian Gonzales
Damacio Gonzales
Chris Hernandez
Paul Miller
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Incident Location: Name of Company
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Adventure
City Of Andrews
ETP
MARTIN'S Yard
Other (please write it)
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Lease Name or Address Where it occured.
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Arrendamiento
Unit # Involved at site:
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Unidad
Description:
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Firma De Empleado
Injured or Incident Person's Signature
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Injured Person's Phone Number
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Witness
Signature #3
Witness
Signature #4
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