English: Model: ______________ Site of accident: ______________ Date of Accident: ______________  Description of accident: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Equipment owner or RSO actions taken: (e.g., care of the victims, immediate repair of equipment, etc.) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Corrective action: (specify dates when implemented) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Comments: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________  Report prepared by:
French: Modèle : ______________ Endroit où a eu lieu l'accident : ______________ Date de l'accident : ______________  Description de l'accident : _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Mesures prises par le propriétaire de l'équipement ou le responsable de la radioprotection : (p. ex. soins des victimes, réparation immédiate de l'équipement, etc.) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Mesures correctives : (indiquer les dates d'entrée en vigueur des mesures) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Commentaires : _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________  Rapport préparé par :