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ACCIDENT REPORT FORM <br /> project: <br /> EMPLOYER <br /> 1. Name <br /> 2. Hail Address {City ar Town) (State) <br /> (No. and Street) <br /> 3. Location, if different from mail address <br /> i <br /> Fi1JURED OR ILL EMPLOY`M <br /> social Security Number <br /> 4. Name (Middle) (Last) <br /> } (First) <br /> i <br /> 5. <br /> Address {C <br /> } <br /> (No. and at <br /> Female (Check one) <br /> 6. Age 7. Ser.: Male ---- <br /> acs <br /> S. occupation not the specific activity employee <br /> (specific job title <br /> ` performing at time of injury) <br /> t <br /> 9. Department injured persons is employed, <br /> (Enter nacre of which <br /> beeni temporarily working in another <br /> even though they.may <br /> department at the time of injury) <br /> THE ACCIDENT OR EXPOSURE PO OCCUPATIONAL ILLT1E55 y <br /> 10. Place of aecident of exposure {No. or Town) (state) <br /> and Street) (City <br /> 11, <br /> ure on emploFer's premises? <br /> Wag place of accident or expos <br /> (Y.es/No) <br /> to ee doing when injured? was employee , <br /> 12. what was the emp y (Be specif is <br /> using tools or equipment or handling material?) <br /> E-1 <br /> MLII 19-80788 - . _. . <br /> i <br />