Full Name*
Employment*—Please choose an option—ContractorEmployeeVisitorOther
Sex*—Please choose an option—FemaleMale
Occupation*
Email Address*
Phone (W)*
Phone (H)*
Home Address*
Date and Time of Incident*
Location Of Incident*
How did the incident happen?*
Was medical treatment given?*—Please choose an option—NoFirst AidNurseDoctorHospital
Name of person giving intial treatment*
Reported to Safety Regulator*—Please choose an option—YesNo
Name of Witnesses
Phone
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