Laserfiche WebLink
i <br /> ACCIDENT REPORT FORM <br /> Page 2 of 2 <br /> 13. How did the accident occur? (Describe fully the events that resulted in the injury or occupational illness. <br /> Tell what happened and how. Name objects and substances involved. Give details on all factors that <br /> led to accident. Use separate sheet for additional space.) <br /> 14. Time of accident: <br /> f 70 <br /> 15. ES witness(es) <br /> to accident (Name) (Affiliation) (Phone No.) <br /> (Name) (Affiliation) (Phone: No.) <br />�s <br /> (Name) (Affiliation) (Phone No.) <br /> OCCUPATIONAL INJURY OR OCCUPATIONAL ILLNESS <br /> 16. 'Describe injury or illness in detail; indicate part of body affected: <br /> ,®r--. <br /> 17. Na1ne the object or substance that directly injured the employee. (For example, object that struck <br /> employee; ti-.e vapor or poison inhaled or swallowed; the chemical or radiation that irritated the skin; or <br /> in cases of strains, hernias, etc., the object the employee was lifting,pulling, etc.) <br /> 18. Date of injury or initial diagnosis of occupational illness: <br /> 19. Did the accident result in employee fatality? Yes ( ) No ( ) <br /> 20. Name and address of physician: <br /> 21. if hospitalized, name and address of hospital: -...�� <br /> Date of report: _ Prepared by: <br /> Official position: <br /> 172-19.R1 NO] <br />