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ACCIODENT AND ELLNESS 1NVEST][GATION REPORT(Continued) <br /> To be completed by the Subsidiary Safety and Health Representative: <br /> Classification of Incident: <br /> E] Injury E] Illness <br /> Result of Incident: <br /> E] First Aid Only <br /> El Days Away From Work <br /> El Remained at Work but Incident Resulted in Job Transfer or Work Restriction <br /> ❑Incident Involved Days Away and Job Transfer or Work Restriction <br /> E]Medical Treatment Only <br /> No.of Days Away From Work <br /> Date Employee Left Work <br /> Date Employee Returned to Work <br /> No.of Days Placed on Restriction or Job Transfer: <br /> [OSHA I Recordable Case Number <br /> To be completed by Human Resources: <br /> SSN: <br /> Date of hire: Hire date in current job: <br /> Wage information: $ per El Hour D Day El Week F-1 Month <br /> Position at time of hire: <br /> Current position: Shift hours: <br /> State in which employee was hired: <br /> Status: 0 Full-time E] Part-time Hours per week: Days per week: <br /> U Temporary job end date: <br /> To be completed during report to workers' compensation carrier: <br /> Date reported: Reported by: <br /> Confirmation number. <br /> Name of contact: <br /> Field office of claims adjuster: A <br /> This form contains iniolmalion relating to employee heardi and mu3t be used in a manner that pfoW=the wrifidentiality of the <br /> employee to the ��possible while the in anon is being usW for oWupalional and health Lurposes. <br /> Form AR-1 Page 4 of 4 <br />