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13. How did the accident occur? (Describe fully the events which resulted in the injury <br />or occupational illness. Tell what happened and how it happened. Name any objects or <br />substances involved and tell how they were involved. Give full details on all factors which <br />led or contributed to the accident. Use separate sheet for additional space. <br />Occupational Injury or Occupational Illness <br />14. Describe the injury or illness in detail and indicate the part of body affected. <br />amputation of right index finger at second joint; fracture of ribs; lead poisoning; dermatitis <br />of left hand, etc.) <br />15. Name the object or substance which directly injured the employee/. (For example, <br />the machine or thing he struck against or which struck him; the vapor or poison he inhaled <br />or swallowed; the chemical or radiation which irritated his skin; or in cases of strains, <br />hernias, etc, the thing he has lifting, pulling, etc.) <br />16. Date of injury or initial diagn <br />occupational illness: <br />Other <br />18. Name and address of physician <br />19. If <br />ized, name and address of <br />of 17. Did employee die? (Check one) <br />Yes r3 No o <br />Date of report Prepared by (Print) I Official <br />