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Plant
*
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Function/Sub-Function
*
Function/Sub-Function is required
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Agency/Sub-Agency
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Location/ Sub-Location
*
Location/ Sub-Location is required
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Shift
*
Select Shift
Shift is required.
Event Date
*
Event Time
*
Enter Valid Date and Time
Event Date & Time is required
Incident At
*
On Site
Off Site
Nature of Injury
*
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Incident Classification
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Other Sub Category
Equipment Involved
Select Equipment Involved
If other, provide details
Material Involved
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If other, provide details
Description of what happened
*
Description of what happened is required
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Immediate Action Taken (Also mention who visited site first and what action was proposed by him? if applicable)
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Employee(s) / Contractor(s) Injured
Employee(s) / Other
*
Name
*
Employee Code
Age
*
Function
Gender
*
Action
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{{victim.Name}}
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Reported By
Name
*
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Function/ Sub-Function
Contact #
Invalid Contact Number.
Employment Type
*
Select Employment Type
Employment Type is required
Witness 1
Name
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Function/ Sub-Function
Contact #
Invalid Contact Number.
Witness 2
Name
Only alphabets are allowed
Function/ Sub-Function
Contact #
Invalid Contact Number.
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