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APPENDIX B (Continued) <br /> ACCIDENT INVESTIGATION FORM <br /> Instructions <br /> 1. Supervisor is to complete this form <br /> 2. Complete for any incident where someone else could be injured by the same cause. <br /> 3. Supervisor is to assure that the corrective actions are completed. <br /> Injured Employee: <br /> Project: Project No: <br /> Date: Time: Months with employer: <br /> ❑ Claim <br /> ❑ Incident/First Aid Only <br /> Brief description of the incident: <br /> Body Part Injured (Circle All Appropriate Responses): <br /> Head Face Neck Shoulder Upper Arm <br /> Elbow Lower Arm Wrist Hand Finger <br /> Thumb Chest Upper Back Lower Back Trunk <br /> Hip Groin Upper Leg Knee Lower Leg <br /> Ankle Foot Toes Respiratory Internal <br /> Eye <br /> Other: <br /> 10275-4 <br /> D U D E K B-3 June 2017 <br />