Information
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Employee Name
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Social Security number
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Incident location
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Investigation Conducted on
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Prepared by
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Initial date and time of injury/incident
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Date and time supervisor was notified
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When was Safety notified.
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Was there an injury?
- yes
- no
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Did he/she receive medical treatment? If yes, please briefly describe treatment and where it was given.
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Where on site did injury occur?
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Please describe in detail the incident and/or injury.
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Please list all witnesses
