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' Original to Manager <br /> cc:Operations Manager <br /> ►� Levine-Fricke-Recon Health&Safety Director <br /> ' INJURY AND ILLINESS INCIDENT REPORT <br /> OFFICE: DEPARTMENT <br /> EXACT LOCATION: DATE OF OCCURRENCE: <br /> Time: - Date Reported: <br /> Name: <br /> ' Occupation: Parts Of Body Affected: <br /> ' Nature Of Injury <br /> Or Illness: <br /> ' Person With Most Control Of <br /> Object/Equi pment/Substance: <br /> Witness: <br /> DESCRIBE CLEARLY HOW THE ACCIDENT OCCURRED: <br /> ' INDICATE BY AN"X"IF YOUR OPINION ACCIDENT WAS CAUSED BY: <br /> ' PHYSICALCAUSES <br /> ❑ Defective Equipment ❑ Improper Dress ❑ Improper Ventilation <br /> ❑ Hazardous Equipment ❑ Improper Guarding ❑ Other <br /> UNSAFE ACTS <br /> ❑ Operating Without Authority ❑ Took Unsafe Position ❑ Unsafe Equipment <br /> ' ❑ Failure to Wear Protective ❑ Used Unsafe Equipment or ❑ Unsafe Loading <br /> Equipment Hands Instead of Equipment <br /> ' ❑ Horseplay ❑ Worked on <br /> Moving(Energized <br /> ❑ Failure to Secure or Want Equipment <br /> ' WHAT ACTIONS WILL BE TAKEN TO PREVENT REOCCURRENCE: <br /> tEMPLOYEE SIGNATURE: REVIEWED BY: <br /> DATE: DATE: <br /> ' INJURY.CDR 091296RYL:SAH <br />