Unwanted Incident Notification System Employee Safety Form
Unit/Place where the Incident Occurred:
Duties of the Employee Exposed to the Incident:
Event Occurrence/Damage Status:
Effect Duration of the Event:
When the Event Occurred:
Unwanted Event Notification:
Done
Not Done
Occupational Accident Notification:
Done
Not Done
Legal Action:
Launched
Not Launched
Unwanted Event:
Physical Exposure
Psychosocial Exposure
Biological Exposure
Chemical Exposure
Radiological and Nuclear Exposure
Description:
Primary Cause of the Incident:
Date of Incident:
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