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ai.�. •� �:- Te"a�.��Y..€�,-{ •: *,_. � � .�''4:x�.',����'q .y?y�a .moi.' fl, <br /> ON <br /> E �€:" <br /> ti°: wt� <br /> �,t-�'^� � -P:.Y.Y��`�- a q.� ,.�a 'fi' • "a ".'S.'i. ,� -':c.,:". <br /> ��: ":�s..io'ri-. sa:,�e fix*- -.'='�,?'4*.:.a:• .y `3�i' .�,_='..'E 7'�AT`'�' 'K„ <br /> irr <br />'"h:e a- ,� ,s •3 w^- '.`� + � ��,,. �. ��� r Sp :s, <br /> GROUNDWATER •Ir.CILI'OLOGY, L;G <br /> A=.d:nt/Incidr.:it {relr hiss) Reror. <br /> D.O.B.�� <br /> Emnioyee's Nie: D•O.H.� <br /> Address, SSS <br /> Job Title:_, Supervisor's Name: <br /> office Locadcn:--- � <br /> Location at Time of Incident- <br /> Date/Time of Incident: <br /> r– <br /> Describe clearly how the accident occurred: <br /> Was incident: Physical Chemical <br /> Pam,of body affected Exposure: Dermal <br /> rigid <br /> left Inhalation <br /> Ingestion ; <br /> Witnesses: t)� 2) <br /> Conditions/aets contributing to this incident <br /> Managers must complete this section: <br /> Explain specifically the corrective action you have taken to prevent a recurrence:`-- <br /> . <br /> Did inj0 <br /> tuect ga to doctor._ WhCre: <br /> When• --------� <br /> Did 'tired go to hospital: Where: <br /> When• -� <br /> Signatures: <br /> t <br /> Eaiployee <br /> Reporting Manager Health & Safety Mana;er <br /> Da____—� Date <br /> ,! Date <br /> 4 te <br /> 'This form must be completed and returned to Health and Safety ManagoD�tor at working <br /> days. The manager will forward a copy to Corporate Health and Safety <br /> a.Jxu.►n <br />