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1 >I <br /> F t <br /> t F <br /> ACCIDENT REPORT FORM <br /> (Continued) <br /> _13. How did the e accident occur?_ <br /> µ (Dekmoe fully the"events wretch resulted in the <br /> injury or occupational illness. Tell what happened'andihow. Name objects and <br /> substances involved. Give`�detatls'ot all factors which"led ItIo'accident. Use separate <br /> sheet"for additionai space.) <br /> 14 Tome of accident: <br /> 15. ES WITNESS` <br /> TO ACCIDENT , (Name)'- (Affiliation) (Phone No. <br /> (Name)p,, ' (Affiliation) (Phone No.) <br /> (Name)` ` t , (Affiliation) (Phone No.) <br /> ti <br /> OCCUPATIONAL INJURY OR OCCUPATIONAL ILLNESS <br /> 16 Describe the u ajury'or illness m detail and{indicia ',the part of the bodv <br /> affected. -� - <br /> Y*Y <br /> + At <br /> 17: Name ,,the object or substance which directly, injured the emplovee. (For <br /> `exampie, object whtcli 'struck employee; the vapor or poison inhaled or <br /> swallowed; the chemncal_or radiation which irritated the skin; or in cases of <br /> strains, hernias, etc., the`object the employee was lifting, pulling, etc. <br /> i <br /> 18. Date of injury or initial diagnosis of occupational illness <br /> (Date) <br /> 19. Did the'accudent result in employee fatality? (Yes or No) <br /> to q=La i/000s r <br />