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� v <br /> ACCIDENT/INCIDENT/NEAR MISS REPORT <br /> Employee's Name: D.O.B. <br /> Address: D.O.H. <br /> SS# <br /> Job Title: Supervisor's Name <br /> Office Location: <br /> Location at Time of Incident: <br /> Date/Time of Incident: <br /> Description: Describe clearly how the accident occurred: <br /> Was Incident: Physical____________________________ <br /> Chemical <br /> Part(s)of body affected: <br /> Exposure:Dermal Inhalation Ingestion <br /> Witnesses: 1) 2) <br /> C o n d i t i o n s / a c t s c o n t r i b u t i n g t o t h i s <br /> incident: <br /> Explain specifically the corrective action you have taken to prevent a recurrence: <br /> Did the injured go to a doctor? When? <br /> Where? <br /> Did the injured go to a hospital? When? <br /> Aft Avalon Environmental Consultants 9627-001-6 <br /> Kashmar Singh Joes Truck Plaza <br /> January 9, 2001 Lathrop,California <br />