Witnesses? Yes ___________ No _____________

Interviewed? Yes __________ No _____________ (If yes, please explain)

__________________________________________________________________________________

__________________________________________________________________________________

Action Taken By Investigator: (Counseling, repair ordered, etc.)

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Investigator: ____________________________________________

When  completed, return form to the Safety Department, Box #85 or McNeil room #202, #204.