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FORM A- Supervisors Report of Accident Form <br /> SAN JOAQUIN COUNTY <br /> SUPERVISOR'S REPORT OF ACCIDENT <br /> Injured Employee: <br /> Department: Phone: <br /> Accident Date Time <br /> Was First Aid or Medical Attention Given? ❑ YES ❑ NO <br /> If so,by Whom? <br /> Physician's Name and Address: <br /> Describe Injury and Part of Body Injured: <br /> Detailed Description of the Accident(Who-What-When-Where-Why) <br /> Names of Witnesses <br /> Cause of Accident(Describe Unsafe Acts&Unsafe Conditions) <br /> Did Employee Lose Time From Work? ❑ Yes ElNo <br /> What Steps Have Been Taken to Avoid Similar Accidents: <br /> SUPERVISOR'S SIGNATURE <br /> ORIGINAL—COUNTY RISK MANAGER <br /> S&T—20 Rev.10/91 QPS CANARY-DEPARTMENT <br /> San Joaquin County <br /> Department of Public Works <br /> County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 22 <br />