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Summary of Hazard:
In the below questions, please answer to the best of your knowledge.
Brief Hazard Description:
Is this a repeat occurrence: Yes No
If this is a repeat occurrence, please provide details of when this has last happened.
Are there other witnesses involved? Yes No
If there are witnesses, please provide names and contact information.
Has management been notified of the concern? Yes No
Have you submitted a hazard complaint with the department? Yes No
If yes, please provide your ticket number:
Have you submitted a facilities request? Yes No
If yes, please provide your ticket number:
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