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ACCIDENT/INCIDENT/NEAR MISS REPORT <br /> Employee's Name: D.O.B. <br /> Address: D.O.H. <br /> SS# - - <br /> Job Title: Supervisor's Name <br /> Office Location: <br /> Location at Time of Incident: <br /> Date/Time of Incident: <br /> Description: Describe clearly how the accident occurred: <br /> Was Incident: Physical Chemical <br /> Part(s) of body affected: Exposure: Dermal <br /> right left Inhalation <br /> ----------------------- <br /> Witnesses: 1) 2) <br /> Conditions/acts contributing to this incident: <br /> Explain specifically the corrective action you have taken to prevent a recurrence: <br /> Did the injured go to a doctor? When? <br /> Where? <br /> Did the injured go to a hospital? When? <br /> Where? <br /> Signatures: <br /> Employee Reporting Manager H&S Manager <br /> CRC Environmental Risk Management,Inc. Project No. 2100-217-2 <br /> American Savings Bank 150 West 10th Street <br /> February 15, 1995 Tracy,California <br />