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r <br /> What was the source responsible for the injury? <br /> What hazardous conditions/methods or lack of protective device(s) that contributed <br /> to the accident/incident? <br /> What unsafe act caused the accidentlincident? <br /> Medical services rendered? hospitalized? <br /> Name of physician and address: <br /> Hospital Name, Address, and Phone Number: <br /> L-- <br /> Note: To be submitted to the Project Health and Safety Officer. <br /> 23 <br />