Accident or Illness
Investigation Report
Date of accident or illness:
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Time of day:
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AM
PM
AM/PM
Date reported:
Location:
Person involved:
Employee
Contractor
Temporary
Visitor
Position title:
Date employed:
Department:
Manager or supervisor:
Witness #1:
Witness #2:
Department:
Description of the
injury or illness:
Description of activity
at the time of the accident:
Accident resulted in:
Injury
Medical clinic treatment
Lost time
Property damage
Illness
No injury or illness
First aid
Recommended
corrective action:
Immediate corrective
action taken:
Investigated by:
Title:
Date
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DD
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2010
2011
2012
2013
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2015
2016
2017
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2020
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2022
2023
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2025
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2030
YYYY
P.O. Box 3311, Grand Rapids, MI 49501, phone: 616.363.6694, fax: 616.363.6697, www.beesteelinc.com