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13. How did the accident occur? (Describe fully the events which resulted in the injury o <br /> 1 occupational illness. Tell what happened and how it happened. Name any objects or <br /> substances involved and tell how they were involved. Give full details on all factors which led <br /> or contributed to the accident. Use separate sheet for additional space. <br /> Occupational injury or Occupational Illness <br /> 14. Describe the injury or illness in detail and indicate the part of body affected. (e.g., <br /> amputation of right index finger at second joint; fracture of ribs; lead poisoning; dermatitis o <br /> left hand, etc.) <br /> 15. Name the object or substance which directly injured the employeell. (For example, the <br /> machine or thing he struck against or which struck him; the vapor or poison he inhaled or <br /> swallowed; the chemical or radiation which irritated his skin; or in cases of strains, hernias, <br /> etc, the thing he has lifting, pulling, etc.) <br /> 16. Date of injury or initial diagnosis of 17. Did employee die? (Check one) <br /> occu ational illness: Yes ❑ No ❑ <br /> Other <br /> 18. Name and address of physician <br /> 19. If hospitalized, name and address of hospital <br /> Date of report Prepared by (Print) Official position <br /> r <br /> 902 Industrial Way•Lodi,CA 95240•209.367.3701 •Fax 209.333.8303 02014 Neil O.Anderson&Associates,Inc. <br />