State Reporting System
Voluntary Reporting Form
A. OWNERS INFORMATION
Date of Occurence
Time of Occurrence
Source(Location/Organisation)
Description of the occurrences,including details of injury,damage,etc
B. HAZARD INFORMATION
1. Description of hazard
Threat
Unsafe-situation
Incident
Self disclosure
Latent condition
Others
2. The hazard is
Temporary (Transient / one-time)
Recurring
Permanent
3. Description of credible consequence
4. Reporter name
5. Reporter contact
Reply Expected?
Yes
No
Note: The Reporter is assured that his/her identity will be protected by the voluntary Reporting System.This information is only to facilitate any necessary clarification with the reporter on the Hazard Information provided,where necessary.
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