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r� <br /> CORPORATE OFFICE 41674 Chrlaty Strati,Fremont-CatlfOmla (415)65"404 <br /> INCIDENVACCIDENT REPORT off <br /> QMTWH <br /> Fremont,CA <br /> �rvtrla,CA Tom ®,AZ Data: <br /> Exceltech Department: <br /> Job Location(On-Ste): <br /> Company(Client)Name: <br /> Company(Client)Address: Street&Numtwr: Ci!y: <br /> County: State: Zip: <br /> Incident Date: Incident Time: incident'..acation: <br /> Name or Person Involved or Injured: Occupation or Title: <br /> Name of Witness: <br /> Describe Incident: <br /> Describe Type of Injury: <br /> Materials Causing injury: <br /> Body Area Affected: <br /> _Was First Aid Given? Yes No Type of First Aid Given: Name d Parses doing First Aid: <br /> Did injured Leave Work?_ Yes No <br /> Was Inured Taken to Doctor Yes No Timo Inju rod Loft Work: Time Injured saw Dr.: Tints Injured Returned to Work: <br /> Did Injured Return to Work? Yes No amlpm am/pm wpm <br /> Leval of Safety Womb f Insured A I B C D <br /> Lightlng Adequate? Yns No <br /> =Work Confined Space? Yes No Heat Stress? Yes No <br /> Cold Temperatures? Yes No I ydork Height? high Law Work in-right S ce? Yes No <br /> Describe Other Conditions: �— <br /> Describe Action Taken to Prevent Futher Occurrence: <br /> Name of Parson Pro ibis Report; <br /> Nemo or Signature of Injurad: <br /> Na <br /> Par1nC ' � <br /> Exceltech Safety Repfessrttstivs: Excettech Department Manager; <br /> Noma of Client Contact: -- Client Phone No.: ( } <br /> Name of Treatment Clinic: <br /> -- Treatment Clir.wc Address: Street a Number: City: <br /> County: State: Zip: <br /> Exceltech Vehicle ID No.: Rented Vehicle: <br /> J <br />