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  • DA'FATE': Incident/ Injury Report Form

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    Direk Rey Coloma
    18 views1 page
    The document is an incident/injury report form for 18 Chams Film Production. It requests personal details of the injured individual such as name, address, contact information, and department. It also asks for details of the incident such as date, time, description of injury, how it occurred, treatment received, and follow up required. The form is to be submitted by the reporting individual and their department head to the production office as soon as possible after an on-set injury.

    Original Description:

    injury report form

    Original Title

    Injury Report Form

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    The document is an incident/injury report form for 18 Chams Film Production. It requests personal details of the injured individual such as name, address, contact information, and department. It also asks for details of the incident such as date, time, description of injury, how it occurred, treatment received, and follow up required. The form is to be submitted by the reporting individual and their department head to the production office as soon as possible after an on-set injury.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    18 views1 page

    DA'FATE': Incident/ Injury Report Form

    Uploaded by

    Direk Rey Coloma
    The document is an incident/injury report form for 18 Chams Film Production. It requests personal details of the injured individual such as name, address, contact information, and department. It also asks for details of the incident such as date, time, description of injury, how it occurred, treatment received, and follow up required. The form is to be submitted by the reporting individual and their department head to the production office as soon as possible after an on-set injury.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    ‘DA’FATE’ Production Office Address:

    Production Company: 18 CHAMRS FILM PRODUCTION


    National Highway, Brgy.
    CN: 05572519
    Timugan, Los Banos, Laguna
    Production Company Address: National Highway, Brgy.
    4030
    Timugan, Los Banos, Laguna 4030
    Tel: 049 501 0100 Tel: 049 549 5790

    INCIDENT/ INJURY REPORT FORM

    PERSONAL DETAILS:

    NAME: ___________________________________________________

    ADDRESS: ___________________________________________________

    ___________________________________________________

    CONTACT PHONE NO: ___________________________________________________

    DEPARTMENT/ POSITION: ___________________________________________________

    MEDICARE NO: ___________________________________________________

    INCIDENT DETAILS:

    DATE AND TIME OF ACCIDENT: ___________________________________________________

    DETAILS OF INJURY: ___________________________________________________

    ___________________________________________________________________________________

    ___________________________________________________________________________________

    HOW THE INJURY OCCURRED: ___________________________________________________

    ___________________________________________________________________________________

    ___________________________________________________________________________________

    TREATMENT: ___________________________________________________

    ___________________________________________________________________________________

    ___________________________________________________________________________________

    FOLLOW UP: ___________________________________________________

    ___________________________________________________________________________________

    ___________________________________________________________________________________

    TIME OFF WORK YES / NO

    Name, address and telephone number of treating doctor (if applicable)


    ___________________________________________________________________________________

    ___________________________________________________________________________________

    Workers Compensation: YES / NO

    Report Submitted by: _________________ Department Head: ________________

    Accounting: _________________ Line Producer: ________________

    Injury reports must be given to the production office as soon as possible.

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