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ACCIDENT AND ILLNESS INVTSTIGATION REPORT(Continued) <br /> Information About the Case(Continued) <br /> What was the injury or illness?Describe the part of the body that was affected and how it was affected;be more specific than <br /> "hurt,""pain,"or"sore."Examples"strained back";"chemical burn,right hand";"carpal tunnel syndrome,left wrist." <br /> Describe the Object or Substance which Directly Harmed the Employee:Examples:"concrete floor';"chlorine"; <br /> "radial arm saw." If this question does not apply to the incident,enter a NA. <br /> Did the employee die? Yes n No❑ Date of death: <br /> Was employee performing regular job duties? Yes F1 No El <br /> Was safety equipment provided? YesEl NoEl Was safety equipment used? Yes El No F1 <br /> Note: Attach any police reports or related diagrams to this accident report. <br /> Witness(es): <br /> Name: <br /> Company: <br /> Street address: <br /> City: State: Zip code: <br /> Telephone number: <br /> Name: <br /> Company: <br /> Street address: <br /> City: State: Zip code: <br /> Telephone number: <br /> Medical Treatment Required? E] Yes E] No E] First Aid only <br /> Name of physician or health care professional: <br /> If treatment was provided away from the work-site,where was it given? <br /> Facility name: <br /> Street address: <br /> City: State: Zip code: <br /> Telephone number: <br /> Was the employee treated in an emergency room? E] Yes R No <br /> Was the employee hospitalized overnight as an in-patient? E] Yes E] No <br /> This form taint relating to empWee health and must be used in a manner ftiat protects the confidentiality of the <br /> employee to ft cAent powible while the information is being used for alional safety and heaM purposes. <br /> Fonn AR-I Page 2 of 4 <br />