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What happened?Tell us how the injury occurred. <br /> Examples,-"When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when <br /> gasket broke during replacement"; "Worker developed soreness in wrist over time." <br /> What was the injury or illness?Tell us the part of the body that was affected and how it was <br /> affected; be more specific than "hurt,""pain," or sore." <br /> Examples.-"strained back"; "chemical burn, hand"; "carpal tunnel syndrome." <br /> What object or substance directly harmed the employee? <br /> Examples.-"concrete floor"; "chlorine"; "radial arm saw." <br /> If the employee died, when did death occur? <br /> Date of death: <br /> Completed By (Full Name): <br /> Title: <br /> Phone: <br /> Date: <br /> AEI Health&Safety,Injury&Illness Prevention Plan Page 18 of 25 <br /> June 24, 2011 <br />