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• ACCIIDENTANCIDENTINEAR MISS REPORT <br /> Employee's Name ❑ O B I I <br /> Address DOH <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 inured go to a doctor? When? <br /> Where? <br /> Did the inured go to a hospital? When? <br /> • <br /> Avalon Environmental Consultants 9627-001-2 <br /> Kashmar Singh Joes Truck Stop <br /> October 20, 1998 Lathrop, California <br />