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HC Productions Injury Report!
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Name
*
First
Last
Email
*
Phone
*
I am reporting a
*
Loss of time/injury
First aid incident
Close call
Observation
Person Reporting Incident
*
First
Last
NamePerson Involved in Incident
*
First
Last
Date and Time of incident
*
Date
Time
Location of Incident
*
Please describe the event in detail
*
Was damage done to the property?
*
Yes
No
Could this incident have been avoided?
*
Yes
No
If so how?
Phone
Witness #1 Phone Number
First
Last
Witness #1 Email
Witness #2
First
Last
Witness #2 Phone Number
Witness #2 Email
Witness #3
First
Last
Witness #3 Phone Number
Witness #3 Email
Submit
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