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- f <br /> F <br /> c <br /> ACCIDENT RE= FORM <br /> (continued) <br /> 13. How did the accident occur? <br /> (Describe fully the events which resulted <br /> E <br /> k <br /> in the injury or occupational illness. Tell what happened and how. Name <br /> objects and substances involved. Give details on all factors which led to <br /> t accident. Use separate sheet for additional space.) <br /> i <br /> 1 <br /> 14. Time of accident: <br /> 15. ES WITNESS TO <br /> ACCIDENT (Name) (Affiliation) (Phone No.) <br /> (Name) (Affiliation) (Phone No.) <br /> (Name) (Affiliation) (Phone Na.) <br /> i <br /> OCCUPATIONAL INJURX OR OCCUPATIONAL ILLNfS: <br /> i 16. Describe the injury or illness in detail and- indicate the pant of the body <br /> } affected. <br /> 17. Name the object or substance which directly injured the employee. (For <br /> example, object which struck employee; the vapor or poison inhaled or <br /> swallowed; the chemical or radiation which irritated the skin; or in cases <br /> of strains, hernias, etc., the object the employee was lifting, Pulling, <br /> i <br /> ei=. <br /> i <br /> 18. Date of injury or initial diagnosis of occupational illness <br /> (Date) - <br /> 19. Did the accident result in employee fatality? (Yes or No. <br /> OTHER <br /> 20. Name and address of physician <br /> k E-2 <br />