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ACCIDENT REPORT <br /> DATE: <br /> NAME OF INJURED PERSON: <br /> ADDRESS OF INJURED PERSON: <br /> PHONE NUMBER(HOME): <br /> COMPANY OF EMPLOYMENT: <br /> ADDRESS OF COMPANY: <br /> COMPANY PHONE NUMBER: <br /> DATE AND TIME OF INJURY: <br /> TIME AND DATE EMPLOYEE BEGAN WORK FOR PROJECT: <br /> SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED,MEDICAL DIAGNOSIS (e.g. <br /> second degree burns on right arm,sprained left ankle etc): <br /> PROJECT DURING WHICH EVENT OCCURRED: <br /> PROJECT MANAGER: <br /> LOCATION WHERE EVENT <br /> OCCURRED: <br /> EQUIPMENT,MATERIALS AND CHEMICAL THE EMPLOYEE WAS USING WHEN EVENT OR <br /> EXPOSURE OCCURRED: <br /> WERE OTHERS INJURED/ILL IN THIS EVENT?(if yes, how many?): <br /> HOW DID INJURY/ILLNESS OCCURRED? DESCRIBE SEQUENCE OF EVENTS. SPECIFY <br /> OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS(use separate <br /> Ceres Associates Project CA519-2 <br /> Western Gravel Co.,Inc. May 20,1999 <br />