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Nature of exposure/injury (parts of body exposed/injured) <br /> Describe how the exposure/injury occurred (attach an additional sheet as necessary) <br /> Medical Care Received (Also list any medications prescribed) <br /> When Where? <br /> By Whom' <br /> Has exposure or injury resulted in <br /> Death9 <br /> Permanent disability9 <br /> Temporary 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 /> Possible/Known cause of injury/exposure <br /> • Operations conducted according to an approved Site Safety and Health Plan Yes ( ) No ( ) If yes, attach copy <br />