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® Corporate Health&SaW - rogram, Part I Effective Date: 12/01/94 <br /> Chapter 21: Emergency Response Plan Revision No.: 1 <br /> Fonn 21.4-1/Exposure and Injury Report (page 4 of 5) <br /> G. How did the exposure/injury occur? (Describe fully what factors led up to and/or <br /> contributed to the incident.) <br /> 9. Attach any other relevant data and information regarding this incident. <br /> 10. Name of person(s) initiating report,job title,and phone number: <br /> Employee Name (Print) Employee Signature Date <br /> Field Team Leader(Print) Field Team Leader Signature Date <br /> Supervisor Name (Print) Supervisor Signature Date <br /> Medical Advisor Comments <br /> Medical Advisor Signature Date <br /> (For RHSR use only) <br /> Review and Comments: <br /> Revised: 9/28/95 page 21-11 <br />