Safety & Health - Employer Incident Report Form

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Number of Affected Employees

Fatalities
In-Patient Hospitalization
Loss of an Eye
Amputation

Employer Information

Employer Contact Name
Title

Business Information

You can look up your NAICS code here.

Address Information

Incident Address

Incident Address

Employer Mailing Address

Employer Mailing Address

Ownership

Ownership Type

Union

Union

Accident Information

Re-order Victim Name Victim Age Occupation Employment Type Weight Operations
Employment Type
more items
Re-order Name Phone Number Email Weight Operations
more items

Accident Description

One file only.
50 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Signature

I agree all information that I am submitting is true to the best of my knowledge.
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