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Incident Investigation Form

This document is intended for internal use, serving as a quick means of communication between workers and management to promptly record incidents that may necessitate notification to the Quality & Safeguards Commission. Please fill out and include all necessary information.

What factors contributed to the incident? Please tick applicable.

ENVIRONMENT

EQUIPMENT / MATERIALS

WORK SYSTEMS

PEOPLE

ACTIONS

If there are any documents supporting the information provided in this incident form, please attach them as part of this form.

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