Equipment Incident Report – MCON Management

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Date of Report *

Name *

First

Last

and of Recommendations

Date of Incident *

Location of Incident *

Name of Person Reporting: *

Job Title *

Supervisor's Name *

Equipment *

Was the Equipment in Use at the Time of the Incident? *

Was the Equipment Being Used Properly? *

Describe the Purpose of Equipment Use at the Time of the Incident: *

Describe What Happened: (Include specific details of the incident, actions leading up to it, and any contributing factors.) *

Was Anyone Injured? *

If yes, describe injuries and attach an injury report if applicable:

Were There Any Witnesses? *

If yes, provide names and contact information:

Was Any Property or Equipment Damaged? *

If yes, describe the damage:

Immediate Actions Taken to Address the Incident: *

Recommendations for Preventing Future Incidents: *

File Upload *

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