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i <br />Supervisor's Report of Incident <br />E A R T H �'r T E C H <br />This is an official document to be initiated by the injured employee's supervisor. Please answer all questions <br />completely. This report must be forwarded to the Health and Safe Section office within 24'hours of the injury. <br />Sex Birthdate <br />Injured's name <br />Ci <br />Home address State Zi <br />Job Title <br />Section Hire date Hourly wage Phone <br />i <br />i <br />Manager <br />Comments on incident and corrective action <br />Manager <br />Print name Signature . Date <br />1_', Health and Safety <br />I, <br />1- <br />i r <br />Concur with action taken? ❑Yes <br />ONO Remarks - <br />OSHA classification <br />❑ Incident only ❑ First aid <br />D No lost work days ❑ Lost work days ❑ Restricted activity Q Fatality <br />Days away from work <br />Days of restricted work <br />Total days charged <br />HS Professional <br />Print name <br />Signature <br />Date <br />