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MAJESTIC TECH <br /> MANAGER'S REPORT OF EMPLOYEE INJURY <br /> .ployee's Name Position SS* <br /> Home Home <br /> Birthdate Address Phone <br /> Job/Project Address Phone <br /> Descripdoa of Work Location of Accident <br /> Date of Injury Time of InjuryTime Reported to Sup Time Shift Began <br /> Description of Incident <br /> Nature of Injury/Part of Body Affected <br /> Manager Job Personnel <br /> Was Incident Witnessed? Yes/No By Whom? <br /> emeat of Witness(es) <br /> Action Taken at Scene <br /> By Whom? <br /> Incident Reported to Manager XesMo When?_ By Whom? To Whom? <br /> Did Employee Leave Work? yes Mo Time Date&Time Employee Rcturaed to Work <br /> First Aid Doccoes Case Follow-Up visit Required Hospitalized <br /> How Did Ac6dcot/In1ury Occur? <br /> Unsafe Conditions Identified <br /> Corrective Aaron Takeo <br /> injured Employee's Signature Date Manager's Signature Daze <br /> Safety Coordinator Daze <br />