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MANAGER'S REPORT OF EMPLOYEE INJURY <br />Employee's Name Position SS# <br />Home Home <br />Birthdate Address Phone <br />Job/Project Address Phone <br />Description of Work Location of Accident <br />Date of Injury Time of Injury Time Reported to Sup. Time Shift Began <br />Description of Incident <br />Nature of Injury/Part of Body Affected <br />Manager Job Personnel <br />Was Incident Witnesed? Ycs/No By Whom? — <br />Statement of Witness(es) <br />Action Taken at Scene <br />By Whom? <br />Incident Reported to Manager? Yes/No When? By Whom? To Whom? <br />Did Employee Lcavc Work? Yes/NQ Time Date & Time Employee Returned to Work <br />First Aid Doctor's Case,-- Follow -Up Visit Required Hospitalized <br />How Did Accident/Injury Occur'? <br />Unsafe Conditions Identified <br />Corrective Action Taken <br />Injured Employee's Signature Date <br />E <br />Man2ger's Signature Date <br />Safety Coordinator Date <br />