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I .Employee's Report of Accident /INJURY <br />Employee's name Age Sex <br />Job position/tide Social Security number <br />Shift hours Days off Supervisors name <br />Date and time of accident L=ation <br />-(in j ury ) <br />Task being performed when accident occurred <br />Date, time cerci ent tyep)orted To whom? <br />Name(s) of witness(es) <br />(injury) <br />Describe how the accident occumd <br />What part of the body was injured <br />Describe the injuries in detail <br />. t <br />Date, time you first sought medical attention <br />Name of doctor and/or hospital <br />Could anything be done to prevent acc dcn of this type? If so, what? <br />Signature of employee Date <br />