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® Corporate Health &Sal'Arogram, Part I Effective Date: 12/01/94 <br /> Chapter 21: Emergency Response Plan Revision No.: 1 <br /> Form 21:4-1/Exposure and Injury Report (page 2 of 5) <br /> Other <br /> 7. Nature of the Exposure/Injury: <br /> a. State the nature of the exposure/injury in detail. List the parts of the body affected and <br /> how the event occurred. (Attach extra sheets if necessary) <br /> b. Did you receive medical care? Yes ( ) No ( ) <br /> C. If so,when? <br /> d. Where? Onsite Offsite <br /> e. By whom? Name of Paramedic <br /> Name of Physician <br /> f. If offsite, name facility(hospital,clinic,etc.);obtain copy of medical report. <br /> g. Length of stay at the facility. <br /> h. Was the Project Manager or Regional Health and Safety Representative contacted? <br /> Yes ( ) No ( ) <br /> When? <br /> i. Did the exposure/injury result in permanent disability? <br /> Yes ( ) No ( )If yes,explain. <br /> j. Has the employee returned to work? Yes ( ) No ( ) <br /> If yes,give date. <br /> Revised: 9/28/95 page 21-9 <br />