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ACCIDENT REPORT FORM <br /> ... <br /> Project: <br /> EMPLOYER <br /> L Name <br /> 2. Mailing Address <br /> (No.and Street) (City or Town) (State) <br /> 3. Location, if different from mail address <br /> 'r INJURED OR ILL EMPLOYEE <br /> 4. Name Social Security Number <br /> (First) (Middle) (Last) <br /> 5. Home Address <br /> (No. and Street) (City or Town) (State) <br /> . 6. Age 7. Sex: Male Female (Check one) <br /> `" 8. Occupation <br /> (Specific job title, =the specific activity employee was <br /> performing at time of injury) <br /> 9. Department <br /> (Enter name of department in which injured person is <br /> .,. employed, even though they may have been temporarily <br /> worldng in another department at the time of injury) <br /> c • THE ACCIDENT OR EXPOSURE TO OCCUPATIONAL ILLNESS <br /> w _L 14. Place of accident of exposure <br /> (No. and Street) (City or Town) (State) <br /> 11. Was place of accident or exposure on employer's premises? <br /> (Yes/No) <br /> APO 12 What was the employee doing when injured? (Be specific-Was employee <br /> � using tools or equipment or handling material?) <br /> I-. <br /> r <br /> L ' <br /> 4 b <br /> tucrMU;f M <br />