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DATE REPORT RECEIVED: ACTIONS TAKEN: REPORT RECEIVED BY: JZP INCIDENT REPORT Date and Time of Incident- Be sure to include AM and PM- Name of Individual Involved/ Individual A;ected Phone Number and Email of Individual Involved/ Person A;ected Name and Role of Induvial Filling out/ Filing the Report Phone number and Email of Individual Filling out/ Filing the Report Safety Incident Property Damage Near Miss Complaint Specific Location of Event (e.g. on apron or near A hangar): Emergency Services or Police Notified? Why or why not? Weather conditions at time of incident- Incident Description- Be specific as possible, were there any injuries, events leading to or immediately following, use extra pages if necessary Were there any witnesses? Yes No If yes, please enter witnesses name and contact information: FOR OFFICAL USE ONLY □ D D D DI D D