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• ACCIDENT REPORT FORM <br /> Dc not use for motor vehicle Or aitoraft acciden s <br /> TO FROM <br /> TELEPHONE (Include area code) <br /> NAME OF INJURED OR ILL EMPLOYEE ` <br /> DATE OF ACCIDENT TIME OF ACCIDENT EXACT LOCATION OF ACCIDENT <br /> NARRATIVE DESCRIPTION OF ACCIDENT <br /> t <br /> NATURE OF ILLNESS OF INJURY AND PART OF BODY INVOLVE- <br /> LOST TIME: YES NO <br /> PROBABLE DISABILITY (Check one) <br /> RisTRrCTSD WORK <br /> FATAL LOST WORK DAYS AWAY FROM WORK -- -- DAYS <br /> NO LOST WORK DAYS FIRST AID ONT.Y <br /> CORRECTIVE ACTION TAKEN . <br /> I <br /> CORRECTIVE ACTIOiI WHICH REMAINS TO BE TAKEN (By whom and when) <br /> NAME OF SUPERVISOR <br /> TITLE <br /> SIGNATURE DATE <br />