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SAN JOAQUIN COUNTY <br /> SUPERVISOR'S REPORT OF ACCIDENT <br /> Injured Employee: =a, <br /> '7,• // ���/•�/�C� /7 <br /> Department: 155VVMJV� p e.a( >� `� Phone: �— /r6 Y ` �41iy 3 <br /> Accident Dated ��� Time <br /> Was First Aid or Medical Attention Given? ❑ YES Pq <br /> NO <br /> If so, by Whom? <br /> Physician's Name and Address: 1d' <br /> Describe Injury and Part of Body Injured: L4-Ty� J}a-e,& _ c,4 _ <br /> Detailed Description of the Accident (Who-What-When-Where-Why) R1� <br /> J <br /> L.L,� t I <br /> Names of Witnesses ,`�tN•t_ <br /> Cause of Accident (Describe Unsafe Acts & Unsafe Conditions) !,j"Lw( �4/r r,1/`�•f 1,f <br /> Did Employee Lose Time From Work? ❑ Yes No <br /> What Steps Have Been Taken to Avoid Similar Accidents: <br /> SUPERVISOR'S IGNATURE <br /> ORIGINAL—COUNTY RISK MANAGER <br /> S&T—20 Rev. 10/91 QPS CANARY- DEPARTMENT <br />