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L <br /> General Field Work;Rules and Safety Regulations <br /> Hygienetics Environmental Services,Inc. <br /> Employee.In]ur' /Exposure Incident Report <br /> Injury <br /> /Exposure <br /> SSN: <br /> Site Name/Client: <br /> Date of Report: Task/Phase: <br /> rIncident Type: [] Possible Excessive Exposure []Excessive Exposure []Injury <br /> Date of Incident: Time of Incident: <br /> Site Conditions at the Time of the Incident <br /> Temperature: Relative Humidity: Precipitation: <br /> LCloud Cover%: Wind Speed&Direction: <br /> Other Factors That May Have Impacted the Site: <br /> Nature of Exposure/Injury <br /> rMaterial Exposed To: Concentration: <br /> Matrix: Physical State: <br /> Part(s)of Body Exposed or Injured: <br /> L <br /> Type or Extent of Injury or Exposure: <br /> Medical Care Received <br /> L <br /> When: Where: <br /> Name of Physician: <br /> Result of Exposure/Iniury <br /> []Death []Permanent Disability []Temporary Disability []Loss of Work Time <br /> [] Other Explain: <br /> r Was Operation Conducted According to an Approved Health and Safety Plan <br /> yes []no Explain: <br /> Who Witnessed the Injury/Incident: <br />,r Was the Injury/Incident due to the Failure of Protective Equipment[]yes []no <br /> Possible Cause of Injury/Incident: <br /> r Page 16 of 32 <br />