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ACCIDENT REPORT FORM <br /> (Continued) <br /> 13. How did the accident occur? <br /> (Describe fully the events which resulted in the <br /> injury or occupationai illness. Tell what happened and how. Name objects and <br /> substances involved. Give details on all factors which led to accident. Use separate <br /> sheet for additional space_) -- <br /> 14. Time of accident: <br /> 1s. ES WITNESS <br /> TO ACCIDENT (Name) (Affiliation) (Phone No.) .- <br /> (Name) (Affiliation) (Phone No.) <br /> (Name) (Affiliation) (Phone No.) <br /> OCCUPATIONAL INJURY OR OCCUPATIONAL ILLNESS <br /> 16. Describe the injury or illness in detail and indicate the part of the body <br /> affected. y <br /> 17. Name the object or substance which directly injured the employee. (For .- <br /> example, object which struck employee; the vapor or poison inhaled or <br /> swallowed; the chemical or radiation which irritated the skin; or in cases of <br /> strains, hernias, etc., the object the employee was lifting,pulling, etc. <br /> L <br /> 18. Date of injury or initial diagnosis of occupational illness <br /> (Date) <br /> 19. Did the accident result in employee fatality? (Yes or No) <br /> LMCAMUMOM <br />