SAFECOM Reported By (Optional) Name _______________________________ Phone_________________ Organization ____________________ Date_____________ Date__________________ Local Time ________________ Injuries? Y N Damage Y N Mo Day Year 24 Hour Circle Circle __ ___ Location ___ ______________________________________________________________________ State EVENT City, Lat.../Long, or Fire Name NARRATIVE: Please provide a brief explanation of the event. Please suggest what actions could be taken to prevent this from occurring again. LESSONS LEARNED: This form is used to report any condition, observance, act, maintenance problem, or circumstance which has potential to cause a safety related mishap. Send to Regional Safety and Equipment Specialist
SAFECOM Reported By (Optional) Name _______________________________ Phone_________________ Organization ____________________ Date_____________ EVENT Date__________________ Local Time ________________ Injuries? Y N Damage Y N Mo Day Year 24 Hour Circle Circle Location ___ ______________________________________________________________________ State __ ___ City, Lat.../Long, or Fire Name NARRATIVE: Please provide a brief explanation of the event. LESSONS LEARNED: Please suggest what actions could be taken to prevent this from occurring again. This form is used to report any condition, observance, act, maintenance problem, or circumstance which has potential to cause a safety related mishap. Send to Regional Safety and Equipment Specialist