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Incident/Hazard Report
We have 48 hours to submit a claim with Icare after the injury has occurred. A claim can be submitted on the Icare website without knowing if the employee will be away for an extended period. This is best practice. The employee in question will need to provide a certificate of capacity to Icare throughout the life of the claim.
Brief description of hazard/incident:
Where is the hazard/incident located in the workplace?
Date the hazard/incident was identified:
DD slash MM slash YYYY
Time the hazard/incident was identified:
Hours
:
Minutes
AM
PM
AM/PM
Recommended action to fix hazard/incident - List any suggestions you may have for reducing or eliminating the problem - For example: Update procedures, improve training or maintenance work:
Date submitted to manager:
DD slash MM slash YYYY
Time submitted to manager:
Hours
:
Minutes
AM
PM
AM/PM
Action taken - Describe what has been done to resolve the hazard/incident?
Has the hazard/incident been acknowledged by management?
Yes
No
Do we consider the hazard/incident fixed?
Yes
No
Name:
First
Last
Position:
Date:
DD slash MM slash YYYY
Photo Upload:
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Max. file size: 80 MB.
