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•r t s � <br /> INJURY REPORT Page 1 of 1 <br /> INJURIES <br /> Injured Person <br /> Name of Address of Injured <br /> SSN Age Sex <br /> Years of Service Time on Present <br /> TitlelClasslficat>iOn <br /> Severity of Injury or Illness <br /> Disabling Non-Disabling <br /> Fatality Medical Treatment <br /> Estimated Number of Days Away From Job <br /> Nature of Injury or Illness <br /> Classification of Injury <br /> Fractures Heat Burns Cold Exposure <br /> Dislocations Chemical Burns Frostbite <br /> Sprains Radiation Burns Heat Stroke <br /> Abrasions Bruises Heat Exhaustion Concussion <br /> Lacerations Blisters Toxic <br /> Punctures Bites Toxic Respiratory Exposure <br /> Faint/Dwiness Dermal Allergy Ingestion <br /> Other Respiratory Allergy <br /> Part of Body Affected <br /> Degree of Disability <br /> Date Medical Care was Received <br /> Where Medical Care was Received <br /> Address (if off-site) <br /> If Hospitalized, Name, Address and Telephone of Hospital <br /> Name, Address and Telephone Number of Physician <br /> INJURY FRIAS/00 <br />