Title Page
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Conducted on
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Prepared by
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Location
Injured Persons Details
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Name:
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Date of Birth:
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Home Address:
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Mobile Tel Number:
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Work Address:
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Work Tel Number:
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Job Title:
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Manager/Supervisor:
Incident Details
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Date of Incident:
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Time of Incident:
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Date Reported:
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Location of Incident:
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1. Was the employee on duty?
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2. Did individual require medical attention?
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Was individual transported to medical care?
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Was individual transported via:
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What type of vehicle?
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3. Individual was transported to:
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Please state details:
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4. If YES to item #2, did the individual refuse medical care?
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Please get the employee to sign the section below to state that they refused treatment.
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Add signature
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5. Was employee in his/her assigned area?
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6. Did employee cease work due to incident?
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What time did work cease?
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7. Is this a NEW injury?
Incident Facts
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1. Description of incident (state all facts clearly using individual’s own words):
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2. Body part affected/impacted:
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3. Needlestick/Sharp/Bloodborne Pathogens Exposure Incident?
Witnesses
- Witness
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Name
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Home Phone Number:
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Address:
Signature of injured person
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(By signing this form, the injured person certifies that the information provided is true to the best of their knowledge)
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Add signature
Signature of Employee’s Supervisor
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(PLEASE NOTE: SIGNING THIS FORM IS NOT AN ADMISSION OF TKL LIABILITY)
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Add signature