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APEX <br />Injury or Illness Information <br />Where did incident occur? (number, street, city, state, zip): <br />On Employer's premises: Yes or No: <br />Specific activity employee was engaged in when accident occurred: <br />All equipment, materials or chemicals employee was using when incident occurred (e.g., the <br />machine employee struck against, the vapor inhaled or material swallowed, what employee was <br />lifting, pulling, etc.): <br />Did employee lose at least one full shift's work?: <br />Has employee returned to work?: <br />Date employer notified of incident: <br />To whom reported: <br />Other workers injured/made ill in this event?: <br />Description of Incident: (Describe fully the incident events. Tell exactly what happened and how it <br />happened so that someone could recreate the incident. Use extra paper if you need.): <br />Does this Accident involve a Motor Vehicle and a Professional Driver?: <br />Does this incident involve a spill or a leak?: <br />If so, material spilled and quantity: <br />Does this incident involve a third party?: <br />If so, name, address and phone number of third party: <br />Investigation Team Member Names and Job Titles: <br />Reviewed by (Names and Job Titles): <br />Page 2 of 2