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Personal Information
Name
Gender
N/A
Male
Female
Other
Unknown
Age
Nationality
Email Address
Phone Number
Mailing Address
Company Name
Company Position
Incident Details
Role
None
Injured
Involved
Member of public reporting event
Person completing form
Person representing injured party
Safety officer
Witness
Description of Involvement
Supervisor Name
Last Break Finish
Breathalyser Result
N/A
Negative
Positive
Not Taken
Vehicle License Plate
Person Admitted Fault
N/A
Yes
No
Has this information been verified?
N/A
Yes
No
Injury Details
Severity of Injury
N/A
Observation
Near-Miss
Less Serious Incident
Serious Incident
Very Serious Incident
What Was Injured (e.g. left leg, finger)
Type of injury (e.g. bruise, sprain, burn)
Place where injury sustained
What Treatment has been Administered
On duty at the time
N/A
Yes
No
List PPE in use
Port Ambulance
N/A
Yes
No
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