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R . :4 @ <br /> ENE <br /> ATE <br /> rv^ <br /> 1 <br /> 1 <br /> FCCTD£\I•r REPORT FORM <br /> Do not use for rotor vehicle or aircraft accidents <br /> l TO FROM <br /> GY TELEPBCNE (include area code) <br /> WiC OF INJURED OR ILL "EMXLOYER <br /> ( 1 <br /> i Y <br /> DATE OF ACCIDENT TIME OF ACCIDENT EXACT LOCATION OF ACCIDF14'T <br /> NARRATIVE DESCRIPTION OF ACCIDENT <br /> E:Ir <br /> i <br /> NATURE OF ILLNESS OF IN3UhY AND PART OF BOD_ INVOLVED <br /> LOST TIME: YES NO 3 <br /> PROBABLE DISABILITY (Check ' one) <br /> j I RrzTRICTED WORK <br /> FATAL LOST WORK HAYS iMAY FROM M WORT. DAY'S <br /> NO LOST WORK DAYS _ rIRST AID ONLY <br /> CORRECTIVE ACTION TAKEN <br /> i <br /> r ' CORRECTIVE ACTION WHICH RMiAINS TO RE TArEN (By wham and when) <br /> N. <br /> NF:ff OF SUPERVISOR TITLE •�� <br /> F• <br /> SIGNATURE DATE <br /> n.. , <br /> 6 <br /> i <br /> • <br />