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El <br />Ir <br />..Employee's Report of Accident /INJURY <br />Employee's name Age Sex <br />Job position/tidc Social Security number <br />Shift hours __ Days off Supervisors name <br />Date and time of accident Location <br />(injury) <br />Task being performed when accident occurred <br />Date, time accuint ported To whom? <br />Names) of witness(es) <br />(injury) <br />Describe how the accident occurred <br />What part of the body was injured <br />Describe the injuries in detail <br />Date, time you first sought medical attention <br />Name of doctor and/or hospital <br />Could anything be dome to prevent a(ccients of this type? If so, what? <br />Signature of employee D� <br />