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Accident/Injury/Illness Information: <br /> Describe accident/injury or illness(if applicable): <br /> Name of person injured: <br /> Organization: <br /> Address: <br /> Phone No.: <br /> Birthdate: <br /> Soc. Sec. No.: <br /> Names of witnesses to accident(if any) <br /> Name Telephone Number <br /> Medical Information: <br /> Describe type of medical attention (include site first aid, persons involved, hospital <br /> address): <br /> Physical examination given under medical surveillance plan: Yes/No <br /> Doctor of Exam: Date: <br /> Signature of Injured: <br /> Date: <br /> 4 <br /> Hrtawrx�dsmaomwapmxnm.nvmc w�sevpoam.o_n.dna mimmc <br />