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(ATTACHMENT 9) <br /> SECOR INJU .LLNESS REPORT(Use additional spa 3 necessary) <br /> DAR3 OF INCIDENT CASE NO. TIME OF DAY <br /> EMPLOYEE NAME DATE OF BIRTH <br /> HOME ADDRESS PHONE NO. <br /> SEX:MALE_ FEMALE_ AGE_ JOB TITLE SOCIAL SECURITY NO. <br /> OFFICE LOCATION DATE OF HIRE <br /> t <br /> WHERE DID INCIDENT OCCUR?(INCLUDE ADDRESS) <br /> ON EMPLOYER'S PREMISES? YES NO PROJECT NAME/NO. <br /> WHAT WAS EMPLOYEE DOING WHEN INCIDENT OCCURRED?(BE SPECIFIC) <br /> HOW DID THE INCIDENT OCCUR?(DESCRIBE FULLY) <br /> WHAT STEPS COULD BE TAKEN TO PREVENT SUCH AN INCIDENT? <br /> OBJECT OR SUBSTANCE THAT DIRECTLY CAUSED INCIDENT? <br /> DESCRIBE THE INJURY OR ILLNESS PART OF BODY AFFECTED <br /> NAME AND ADDRESS OF PHYSICIAN <br /> IF HOSPITALIZED,NAME AND ADDRESS OF HOSPITAL <br /> LOSS OF ONE OR MORE DAYS OF WORK?YES/NO IF YES-DATE LAST WORKED <br /> HAS EMPLOYEE RETURNED TO WORK?YES/NO IF YES-DATE RETURNED <br /> DID EMPLOYEE DIE?YES/NO IF YES,DATE <br /> COMPLETED BY(PRINT) EMPLOYEE SIGNATURE <br /> (Supervisor or Site Health&Safety Officer) <br /> DATE <br /> SIGNATURE <br /> PIC SIGNATURE <br /> DATE <br /> DATE <br /> This report must be completed by the employee's supervisor or Site Health and Safety Officer immediately upon learning of the incident. The completed report must be <br /> reviewed and signed by the Principal-in-charge and transmitted to Corporate Health and Safety within 24 hours of the incident,even if employee is not available to review <br /> and sign. Employee or employee's doctor must submit a copy of the doctor's report to Corporate Health and Safety within 24 hours of the initial exam and any subsequent <br /> exams. REV:426-95 <br /> H ASFM\STOCKTONU_t NCOLN2.11S <br />