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S <br />9 <br />0 <br />ACCIDENT REPORT FORM <br />Supervisor's Report of Accident <br />To: <br />Name of injured or ill employee: <br />Date of accident: <br />Exact location of accident: <br />Narrative description of accident: <br />From: Phone: <br />Time of accident: <br />Nature of illness or injury and part of body involved: <br />Lost time: —Yes —No <br />Probable disability (please circle one) <br />Lost work day with <br />days away from work <br />No lost work days <br />Lost work day with days <br />of restricted activity <br />Corrective action taken by reporting unit: <br />Fatal <br />0 <br />Corrective action which remains to be taken (by whom and when): <br />Name of Supervisor: <br />Signature: <br />Title: <br />Date: <br />First aid <br />only <br />