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HSE Incident Form

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Your reference number: {{HSE_ApplicationForm.ReferenceNumber}}.
Please copy this URL to check your submission details.

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Reference Number: {{HSE_ApplicationForm.ReferenceNumber}}
Classification of Incdient *
{{HSE_ApplicationForm.ClassificationIncident}}
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Details of Incident *
Incdident Date and Time *:
{{HSE_ApplicationForm.DateAndTimeOfIncident}}
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Only past date is allowed
Only future date is allowed
Description of Exact Location where the incdient occured *:
{{HSE_ApplicationForm.DescriptionOfLocationIncident}}
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Description of Details *:
{{HSE_ApplicationForm.DescriptionOfDetailsIncident}}
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Proposed Action *:
{{HSE_ApplicationForm.ProposedActions}}
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Notification
N/A Note: DHCR - HSE Dept. is automatically notified.
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Category of Event *
{{HSE_ApplicationForm.CategoryOfEvent}}
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Internal Reporting
Full Name *:
{{HSE_ApplicationForm.InternalReportingFullName}}
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Department/Facility *:
{{HSE_ApplicationForm.InternalReportingDepartment}}
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Injury
Any Injury?
{{HSE_ApplicationForm.AnyInjury==true?'Yes':(HSE_ApplicationForm.AnyInjury==false?'No':'N/A')}} N/A
Body Part Affected
{{BodyPart}}
N/A {{HSE_ApplicationForm.OtherBodyPart}}
{{HSE_ApplicationForm.OtherBodyPart}}
Others:
{{HSE_ApplicationForm.OtherBodyPart}} N/A
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Witness Information
Full Name:
{{HSE_ApplicationForm.WitnessFullName}} N/A
Gender:
{{HSE_ApplicationForm.WitnessGender}} N/A
Age:
{{HSE_ApplicationForm.WitnessAge}} N/A
Department/Facility:
{{HSE_ApplicationForm.WitnessDepartment}} N/A
Witness Status:
{{HSE_ApplicationForm.WitnessStatus}} N/A
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Addtional Information:
{{HSE_ApplicationForm.WitnessAdditionalnfo}} N/A
Submitter Information
Submitter Name*:
{{HSE_ApplicationForm.SubmitterName}}
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Submitter Email*:
{{HSE_ApplicationForm.SubmitterEmail}}
This feild is required{{Resources.RequiredMsgChoose+Resources.Category}}
Please enter a valid email{{Resources.RequiredMsgChoose+Resources.Category}}

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