Information
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Cooperative Name:
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Select date
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Auditor Name:
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Personnel Assisting with the Investigation:
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Date and Time of Injury:
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Provide Name(s) of Employee(s) Injured:
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Job Title(s):
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Job being performed and location:
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Describe injury in detail and part of body injured:
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Pictures of injury if needed:
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How did the accident / injury occur?
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Pictures of accident scene if needed.
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Witness name, address, and phone number
Auditor Verification Signature
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Auditor Verification Signature:
