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Inciden t Repor t Form

Repor t an y inciden t includin g injury , propert y damage , o r yout h protectio n event: Immediatel y followin g th e incident , cal l th e Program Superviso r a t _(916 ) 825-7166 Follow u p b y immediatel y completin g an d faxing this form to Sacramento START at _(916) 808-1214

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Inciden t Repor t Form

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  1. Reportanyincidentincludinginjury,propertydamage,oryouthprotectionevent:Reportanyincidentincludinginjury,propertydamage,oryouthprotectionevent: Immediatelyfollowingtheincident,calltheProgramSupervisorat_(916)825-7166 Followupbyimmediatelycompletingandfaxingthisform toSacramentoSTARTat_(916)808-1214 PLEASEPRINTCLEARLY IncidentReportForm

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