SHEQTool

Reporter Type

Date

Time

Originator

Details of Complaint

Date

Time

Person Reporting Incident

Email Address

Person Reporting Contact Number

Incident Category

Incident Category Type

Description of Incident

Injured Person

Injured Party contact Details

Type of injury

N/A

Head Injury

Upper Body Injury

Lower Body Injury

Arms

Legs

Torso

Hands

Feet

Fingers

Toes

Eye

Ear

Face

Nose

Mouth

Detail of incident and injury sustained

Additional Injured / Affected parties and contact details

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1

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