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Site Health and Safety Plan <br />19133 East Liberty Road, Clements, California <br />August 16, 2022 <br />Page 41 <br /> <br />Sharp Environmental Technologies, Inc. <br />16. 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 /> <br />Describe bodily injury sustained (be specific about body part[s] affected): <br /> <br />Recommendation on how to prevent this accident from recurring: <br /> <br />Name of supervisor: Phone: <br /> Last First <br />Name(s) of witness(es): Phone: <br /> (Attach report[s] of witness[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 />