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EMPLOYEE'S REPORT OF INJURY <br /> ' (To be completed by employee only) <br /> Employee name: Male Female <br /> ' Last First Middle <br /> Date of birth: Home phone: ( ) <br /> ' Home address: <br /> City: State: Zip code: <br /> ' Present title: AA&A employee since: <br /> Social Security no.: — — Weekly salary: <br /> Accident location: <br /> Address Area(loading dock,bathroom,etc.) <br /> ' Date of accident: Time of accident: <br /> Describe fully how accident occurred(including events that occurred immediately before accident): <br /> t <br /> ' Describe bodily injury sustained(be specific about body part[s] affected): <br /> 1 <br /> ' Recommendation on how to prevent this accident from recurring: <br /> Name of supervisor: Phone: <br /> Last First <br /> Name(s)of witness(es): Phone: <br /> ' (Attach report[s]of wftness[es]) <br /> When did you report the accident to your supervisor? <br /> ' To whom did you report the injury? <br /> Do you require medical attention? Yes No Maybe <br /> Name of your treating physician: Phone: <br /> ' Employee signature: Date: <br /> Ami Adini <br /> t &Assoclates.inc. <br />