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Employee Incident Report

  1. provide all details, including the type of work activity in process, specific incident details, and any contributing factors

  2. Be specific (left, right, upper, lower, etc)

  3. (i.e. cut, bruise, strain, etc)

  4. Was Treatment Received for Injury?

  5. NOTE: for vehicles, list year, make & VIN

  6. Attach any documents, photos, law enforcement reports, or other related documents

  7. Leave This Blank: