Question: INCIDENT REPORT FORM PART A - To be completed by the employee Name of employee who was injured: Name of employee completing this form: Time

INCIDENT REPORT FORM PART A - To be completed by the employee Name of employee who was injured: Name of employee completing this form: Time of accident/incident: 3pm Date: 15 October 20XX Work area: Describe the hazard/detail what happened - include area and task, equipment, tools and people involved. (Include at least three contributing factors from the case study) Possible solutions/how to prevent recurrence (do you have any suggestions for fixing the problem or preventing a repeat?) (Include at least three solutions)

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