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MEMBER INFORMATION

*Name: (required)

*Employee No./Badge: (required)

*Job Classification: (required)

*Work Location: (required)

*Email: (required)

*Phone: (required)

Address:

City:

Postal Code:


INCIDENT/ISSUE INFORMATION

*Date: (required)

*Time: (required)

*Location: (required)

*Weather: (required)

*Type: (required)

DESCRIPTION OF INCIDENT/ISSUE:

*Did you report this to the employer? (required)

If yes when, to whom?
Name:

Contact Information:

If no, please explain?

Were emergency services involved? If so, which one(s) (Police/Fire/Ambulance)?


WITNESSES

Name:

Contact Information:


Name:

Contact Information:


Name:

Contact Information:


By clicking ‘SUBMIT FORM’ you will be sending this report to your Local 1587. You will also receive a copy of the report in your email inbox for your own records.