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• ACCIDENTIINCI DENTIN EAR MISS REPORT <br /> Ilk Employee's Name DOB <br /> Address DOH I I <br /> SS# - - <br /> Job Title Supervisor's Name <br /> Office Location <br /> Location at Time of Incident <br /> DatetT,me of Incident <br /> r <br /> Description Describe clearly how the accident occurred <br /> 1 <br /> Was Incident Physical <br /> Chemical <br /> 10 Part(s)of body affected <br /> Exposure Dermal Inhalation ingestion <br /> Witnesses 1) 2) <br /> C o n d i t i o n s / a c t s c o n t r i b u t i n g t o t h i s <br /> 1 incident <br /> 1 ' <br /> 1 Explain specifically the corrective action you have taken to prevent a recurrence <br /> Did the injured go to a doctors When? <br /> Where? <br /> I <br /> Did the injured go to a hospital? When? <br /> Avalon Environmental Consultants 9627-001-7 <br /> Kashmar Singh foes Truck Plaza <br /> February 1,2002 Lathrop,California <br />