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INJURY REPORT Page 1 of 1 <br />INJURIES <br />Injured Person <br />Name of Address of Injured <br />SSN Age Sex <br />Years of Service Time on Present IrAh <br />Title/Classification <br />Severity of Injury or Illness <br />Disabling <br />Fatality <br />Estimated Number of Days Away From Job <br />Nature of Injury or Illness <br />Classification of Injury <br />Fractures <br />Heat Burns <br />Dislocations <br />Chemical Burns <br />Sprains <br />Radiation Burns <br />Abrasions <br />Bruises <br />Lacerations <br />Blisters <br />Punctures <br />Bites <br />Fai ' ess <br />Dermal Allergy <br />Other <br />Part of Body Affected <br />Degree of Disability <br />"TV -1 <br />Where Medical Care was Received <br />Address (if off-site) <br />Name, Address and Telephone Number of Physician <br />Cold Exposure <br />Frostbite <br />Heat Stroke <br />Heat Exhaustion Concussion <br />Toxic <br />Toxic Respiratory Exposure <br />Ingestion <br />Respiratory Allergy <br />