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i <br /> GRDUNDWAT`'R '[; OLOG�, INC <br /> Accident/Incident(near miss)Report <br /> 0.B. <br /> Employee' s Name' y <br /> € D.O.H. <br /> Address: ` <br /> SS# <br /> Job Title' Supervisors Name: <br /> Office Location: 1 <br /> Location at Time. of Incident: <br /> Date/Time of Incident: a <br /> sszasxssa==¢:as sasssssss=aaszszssa`aszssssssszsaRs=Rsyss=sazszaz.a <br /> Description: Describe clearly how the accident occured:_� <br /> I� L <br /> h <br /> fl i <br /> Was incident: Physical Chemical <br /> Part' s of body affected Exposure: Dermal <br /> right left Inhalation_„_ <br /> Ingestion <br /> Witnesses : 1) + 2} <br /> - arias=a=sssssssss:z=a=satsss=ssz::ft�haaasssszssssszs�zsa=. <br /> Conditions/acts contributing to "thirs incident <br /> Explain specifically the corrective action you have taken to <br /> prevent a recurrence: j <br /> f <br /> Did injured go to doctor: Where <br /> 1When <br /> y <br /> Did injured go to hospital: Where <br /> ' F <br /> When <br /> syra3z=�=aa�Ra�a=ssszzaaaaazaa3.-sem¢-aasz- <br /> .Signatures : <br /> a � <br /> Employee Reporting Manager Regional HSS Director <br /> Date Date Date <br /> This form must be completed and; returnwhotwill gforward ional ealcopy <br /> Safety Director within 1 workin`9 days <br /> to corporate 'Health & Safety Director at ELD. <br /> 008 .FRM.PP-1 <br />