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r <br /> ACCIDENTANCI DENT INVESTIGATION REPORT <br /> Month/DayNear of report Prepared by: Title: <br /> Company name: Address: Phone number: <br /> Name of workers compensation: Policy number: <br /> Name of employee: Home Social security number: <br /> address: <br /> Male or female: Married or single: No. of children: <br /> Date and time of accident/incident: Did employee die? <br /> How did the accident/incident occur? <br /> What part(s) of the body were affected: <br /> Engaged in what type of task when injured? <br /> 22 <br />