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Craft Beer
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Spirits
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Injury/Near Miss Report
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approximate testing. cost
Incident Type
*
Injury
Property Damage
Near Miss
Environmental
Other
Please explain the Other Incident Type
*
If property damage, cost of repairs associated:
Drug/alcohol testing required:
*
Yes
No
Please explain the reason(s) for testing.
*
Mobile Equipment Incident
Disregard for Safety Policy
Reasonable Suspicion (Complete RS Form)
Significant Incident - Failure to Follow Safety
Something else
Please explain.
*
Employee name:
First
Last
Enter the name and phone # of each witness:
Name
Phone #
Date and approximate time of incident:
Date
Time
Location of Incident
*
Describe the Injury (strain, cut, bruse, etc.):
*
Part of the body affected (e.g. hand, foot, etc.):
*
Was medical treatment required?
*
No
First Aid Only
Urgent Care/Emergency Room
Describe the Incident fully:
*
Detailed list all equipment, machinery, materials or chemicals the employee was using when the event occurred:
*
Were proper procedures being followed when the incident occurred?
*
Yes
No
Please explain your "No" response.
*
How could this incident have been prevented?
*
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Are you over 21 years of age?
Beer Me!
Root Beer Me!
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