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® Corporate Health&Wei_ .-rogram, Part I Effective Date: 12/01/94 <br /> Chapter 21: Emergency Response Plan Revision No.: 1 <br /> ®Tetra Tech, Inc. Form 21.4-1 <br /> Exposure and Injury Report For Employees <br /> of Tetra Tech and Its Subcontractors <br /> (page 1 of 5) <br /> Project Number: Date: <br /> 1. Employee Name: Company: <br /> 2. Employee ID No.: <br /> 3. Sex: M F 4. Age: _ 5. Office: <br /> 6. Incident: <br /> a. Type—Possible Exposure Exposure <br /> Physical Injury <br /> b. Location <br /> C. Date of Incident Time of Incident <br /> d. Date of Reporting Incident <br /> e. Date of Initial Diagnosis <br /> f. Person to Whom Incident was Reported <br /> g. Weather Condition During Incident T Temperature <br /> h. Wind Speed and Direction Humidity <br /> Cloud Cover Clear Precipitation <br /> i. Name of Materials Potentially Encountered: <br /> Chemical(e.g.,liquid,solid,gas,vapor, fume,mist) <br /> Radiological <br /> Revised: 9/28/95 page 21-8 <br />