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ACCIDENTANCIDENT/NEARMISS REPORT <br /> Employee's Name: D.O.B. / <br /> Address: D.O.H. I I <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: Exposure: Dermal <br /> right left <br /> 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 /> CRC Environmental Risk Management,Inc. Project#2100-250-2 <br /> American Savings Bank 222 North Et Dorado Street <br />' April 6, 1995 Stockton, California <br />