Accident & Near Miss Report

Type of Report

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Who is submitting this report?

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Person  involved in the accident, near miss or Incident.

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Did an injury occur?
Medical treatment required?
If yes, what type?
Did the employee leave work early due to the injury?

Describe Accident

Damage to Equipment or Injury to Person

Where proper procedures being followed when the incident occurred?
Was the employee wearing proper personal protective equipment
Where proper procedures being followed when the incident occurred?

Accident Report Submitted

Contact:

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Chris Tibbs

President & CEO

(360) 801-0116

CTibbs@penarc.org

Kim Bushnell.jpg

Kim Bushnell

Chief Operating Officer

(360) 801-0628

KBushnell@penarc.org

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George Skurtu

Director

(360) 801-2841

GSkurtu@penarc.org