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® Corporate Health&Safe0rogram, Part I Effective Date: 12/01/94 <br /> Chapter 21: Emergency Response Plan Revision No.: 1 <br /> Form 21 M Exposure and Injury Report (page 3 of 5) <br /> k. List the names of other persons affected during the incident: <br /> 1. List the names of persons who witnessed the exposure/injury incident: <br /> 8. Possible Cause of the Exposure/Injury- <br /> a. What was the name and title of the field team leader or immediate supervisor at the site <br /> of the incident? <br /> b. Was the operation being conducted under an established safety plan? <br /> Yes ( ) No ( ) If yes,attach a copy. If no,explain. <br /> C. Were protective equipment and clothing used by the employee? <br /> Yes ( ) No ( ) If yes,list items: <br /> d. Did any limitations in safety equipment or protective clothing contribute to or <br /> affect exposure?If yes,explain: <br /> e. What was the employee doing when the exposure/injury occured? (Describe briefly as <br /> "Site Reconnaissance," "Site Categorization," "Sampling," etc.) <br /> f. Where exactly onsite or offsite did the exposure/injury occur? <br /> Revised: 9/28/95 page 21-10 <br />