OH&S Report Form
Please fill out the following form
to report an incident to management
Your Name
Date of incident
Email
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness, or injury?
No
Yes
If you answered yes to any question, please elaborate
Initials
I declare that the info I’ve provided is accurate & complete
Submit
Thanks for submitting!
