Information
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Conducted on
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Prepared by
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Location
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Date / Time of,Accident:
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Name of HEL employee driving vehicle:
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Date / Time Reported to Foreman/Supervisor:
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Date / Time Reported to Management:
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Accident Location:
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Local Police called?
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HEL vehicle involved (unit number)
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Damage to HEL vehicle?
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HEL VEHICLE PIC#1
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HEL VEHICLE PIC#2
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HEL VEHICLE PIC#3
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Damage to Other Vehicle?
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OTHER Pic#1
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OTHER Pic#2
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OTHER Pic#3
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Foreman / Construction Foreman / Supervisor:
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Any Injuries?
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Any Blood Exposure? If Yes, whose blood and who was exposed?
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List Names:
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Witnesses? If Yes, list their names.
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LIST Names:
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DESCRIPTION OF HOW ACCIDENT OCCURRED?
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Any Other Information?
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Name of Person Completing this Notice: