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ACCIDENT/INCIDENT/NEAR MISS REPORT <br /> Employee"s Name: D.O.B. <br /> Address: D.O.H. <br /> SS## - - <br /> Job Title: Supervisor's Name <br /> Office Location: <br /> Location at Time of Incident: <br /> Date/Time of Incident: <br /> Description: Describe clearly how the accident occurred: <br /> Was Incident: Physical Chemical <br /> Part(s)of body affected: <br /> Exposure:Dermal Inhalation Ingestion <br /> Witnesses: '1) 2) <br /> Conditions/acts contributing to this incident: <br /> Explain specifically the corrective action you have taken to prevent a recurrence: <br /> Did the injured go to a doctor? When? <br /> Where? <br />' Did the injured go to a hospital? When? <br /> Where? <br /> Signatures: <br /> Employee Reporting Manager H&S Manager <br />