Time Reported
HH:MM (24H)
Location Area

Incident Location - If incident occurred off property,

Date Reported *
YYYY/MM/DD

Off

"OFF -

or on a public roadway, please select

Property

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Select Map Location, if required (defaults to computer location, navigate map to incident location and

Describe the specific location in more detail, if required and attach photos when applicable
click Update)

(address/intersection/sub-area/room #, etc) *

How would you classify this event? *

City *

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Describe your safety concern or near miss in detail (describe what is wrong, including risk to

workers/customers. example: leaking pipe causing water to pool on floor.) *

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