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® Corporate Health&Safe#ogram, Part I Effective Date: 12/01/94 <br /> Chapter 21: Emergency Response Plan Revision No.: 1 <br /> Form 21 A-1lExposure and Injury Report (page 5 of 5) <br /> Action Required: Yes ( ) No ( ) <br /> If yes,what action? <br /> Follow-up action carried out: <br /> Regional Health and Safety Representative (Signature) Date <br /> Explain Corrective Actions to be Taken to Prevent Similar Recurrences: <br /> Project Manager/Field Team Leader (Signature) Date <br /> Employee Signature Date <br /> Revised: 9/28/95 page 21-12 <br />