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• k. <br /> x <br /> 1 <br /> ACCIDENT REPORT FORT! <br /> DO not Use for motor vehiCl,e or aircraft accidents <br /> w� <br /> TO FROM <br /> TEZEPEONF (Inc)jde area code) <br /> i <br /> NAME OF IN:,URED OR FLT, EMPLI?YEE <br /> } <br /> DATE OF AC DENT --- .,� <br /> TIMs` 0, ACCIDENT EXACT LOCATION OF ACCIDENT <br /> -i NARRATIVE DESCRIPTION OF ACCID5 <br /> i . <br /> Y� NATURE OF ILLNESS OF INJURY AND PART Of" BODY INVOLVED <br /> LOST <br /> TIME- YES <br /> NO <br /> PROBABLE DISABILITY (Check <br /> � <br /> onei' :TESTRICTED WORE <br /> FATAL LOST WOES DAYS AWAY FROM WORK ----- DAYS <br /> .. NO LOST WORK DAYS FIRST AIB ONLY <br /> r CORRECTIVE ACTION <br /> CORRECTIVE ACTION WHICH REMAINS TO BE TAIKEI (By wham and when) <br /> -- NAME OF SUPERVISOR TITLE <br /> SIGNATURE _ <br /> DATE <br /> - J <br />