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ACCIDENT REPORT FORM <br /> - <br /> Project- <br /> i <br /> EMPLOYER <br /> 1.=Name <br /> 2. Mailing Address <br /> (No. and Street) (City or Town) (State) <br /> 3. Location, if different from mall address <br /> INJURED OR ILL EMPLOYEE <br /> 4 Name Social Security Number <br /> � (First) (Middle) (Last) <br /> 5. Home Address <br /> (No. and Street) (City or Town) (State) <br /> 6. Age 7. Sex: Male Female (Check one) <br /> I <br /> 8. Occupation <br /> (Specific job title, =the specific activity employee was <br /> performing at time of injury) r <br /> 9. Department <br /> (Enter name of department in which injured person is <br />}� employed, even though they may have been temporarily <br /> working in another department at the time of injury) <br /> THE ACCIDENT OR EXPOSURE TO OCCUPATIONAL ILLNESS <br /> � 10. Place of accident of exposure <br /> (No. and Street) (City or Town) (State) <br /> 11. Was place of accident or exposure on employer's premisesh <br /> (Yes/No) <br /> 12. What was the employee doing when injured? (Be specific - Was employee <br /> using tools or equipment or handling matenal?) <br /> f <br /> i <br /> b <br /> e <br /> tMc/Z uml/0008 <br />