Laserfiche WebLink
• GENESIS ENGINEERING&REDEVELOPMENT <br /> INJURY REPORTING FORM <br /> Name of injured person: <br /> Company Name and Address: <br /> Age: Sex: SSN: <br /> Summary of incident: (provide detail and parts of body affected.) <br /> Type of incident: Possible chemical exposure Physical incident Other <br /> Chemical name and form (liquid, solid, gas, fume, mist) <br /> Date of Incident: Time of incident: <br /> Weather conditions at time of incident: (temperature,precipitation, wind speed, and direction) <br /> Was medical care provided on-site?Yes No <br /> If yes, when and where was care provided <br /> By whom: <br /> If"off-site" care was provided,provided name and location of health-care facility: <br /> Nature of care at the health-care facility: <br /> Was the Site Health and Safety Coordinator contacted? Yes No <br /> If no,who was contacted? <br /> Has the employee returned to work? Yes No <br /> If yes, on what date? <br /> Provide names of persons who witnessed the exposure/injury incident. <br /> • <br /> 1 of 2 <br />