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0 <br /> ACCIDENT AND ILLNESS EIPMTIGATION REPORT <br /> To: by: <br /> Subsidiary Health and Saft Representative Prepared <br /> Position: <br /> Cc: Office: <br /> Workers Compensation Adm'=straw <br /> Project name: Telephone number: <br /> Project number. Fax number. <br /> Information Regarding Injured or III Employee <br /> Name: Office: <br /> Home address: Gender. M[] F❑ No.of dependents: <br /> Marital status: <br /> Home telephone number: Date of birth: <br /> Occupation(regular job title): Social Security Number: <br /> Department: <br /> Date of Accident: Time of Accident- &m. El p.m. El <br /> Time Employee Began Work: El Check if time cannot be determined <br /> Location o Accident <br /> Street address: <br /> City,state,and zip code: <br /> County: <br /> Was place of accident or exposure on employer's premises? Yes FI NoE] <br /> Information About the Case <br /> What was the employee doing just before the incident occurred?: Describe the activity,as well as the tools, <br /> equipment,or material the employee was using. Be specific. Examples:"climbing a ladder wbile carrying roofing materials-, <br /> "spraying chlorine from hand sprayer',"daily computer key-entry." <br /> What Happened?: Describe how the injury ocwrrrA Examples:"When ladder slipped on wet floor,worker fell 20 fi=V; <br /> "Worker was sprayed with chlorine when gasket broke during replacement";"Worker developed soreness in wrist over time." <br /> T ltls Yarm co o informaoun relating to employee health and must be usw in a manner that protects the Conftlentlallty of ft <br /> employee tohe oftnt powible while the information is W2g used for occupational!!!2!y and heaM purposes. <br /> Form AR-1 Page 1 of 4 <br />