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Has exposure or injury resulted in: <br /> Permanent <br /> Death? <br /> Temporary disability?- <br /> disability? <br /> Time off work? <br /> List dates: <br /> Restricted duty? <br /> List dates: <br /> Other individuals affected/involved: <br /> Witnesses (attach statement as available) <br /> 1 <br /> Possible/Known cause of injurylexposure: <br /> Operations conducted according to an approved.Site Safety and Health Plan? Yes ( ) No{ )If yes, attach copy. <br /> Was injury/exposure due to failure of protective equipment? Yes ( ) No( ) <br /> t <br /> Explain: ** h f ** <br /> I' Employee signature Date ------------------ <br /> E <br /> Regional Health and Safety Officer Comments: <br /> i <br /> Regional Health and Safety Officer sigsam ----------------- <br /> Corporate Health and Safety Officer.Comments <br /> Corporate Health and Safety Officer signature <br />