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1 <br /> ' ACCIDENTIINCIDENT REPORT FORM <br /> (Sheet I of 2) <br /> FIELD TEAM LEADER'S REPORT OF ACCIDENTANCIDENT <br /> (USE FOR ON-SITE ACCIDENTS OR EXPOSURES ONLY) <br /> 1 <br /> To <br /> ' From <br /> Telephone Number / <br /> ' 1 <br /> Name of Injured/Ill Employee <br /> ' Date of Accident/Incident <br /> Time of Accident/Incident <br /> ' Exact Location of Accident/Incident <br /> Description of Accident/Incident <br /> ' Nature Of Illness or Injury and Part Of Body Involved <br /> ' Probable Disability (check one) <br /> Fatal <br /> ' Lost work days (No of days ) <br /> Restricted activity (No of days } <br /> ' No lost work days <br /> First aid only <br /> ' Hospitalization <br /> D - 1 <br />