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�1 <br /> ACCIDENT REPORT FORM <br /> Do_ not use for motor vehicle or aircraft accidents <br /> ------------------------------------------------------------------------- <br /> F� <br /> TO FROM <br /> i� <br /> t <br /> TELEPHONE (Include area code) <br /> s� NAME OF INJURED OR ILL EMPLOYEE <br /> --- ------------------------ ----------- ------ <br /> -T-L---C-A-T-I-0-NO---FC-IBE <br /> --A-C- --NT- -- <br /> � DATETOF ACCIDENT TIME-OF-ACCIDENT ^ExACT-LDCATION OF ACCI--DENT <br /> €� <br /> --AR---T-1-VEDE----5 <br /> NARRATIVDESCRIPTION OF ACCIDENT <br /> -_------------------------------------------------------------------------ <br /> NATURE OF ILLNESS OF INJURY AND PART OF BODY INVOLVED <br /> €r LOST TIME: YES______ ND-____ <br /> _____--------------------__---------------------------------------------- <br /> PROBABLE DISABIl..ITY (Check one) <br /> RESTRICTED WORE,' <br /> FATAL____ LOST WORK DAYS AWAY FROM WORE: ----- <br /> DAYS <br /> NO LOST-WORF; DAYS <br /> FIRST AID ONLY <br /> --------------------------------------------------..___________-__-____-_- <br /> CORRECTIVE ACTION TAF-"EN <br /> ____________________------------------------------------------------------ <br /> ___________ - __ <br /> CORRECTIVE ACTION �WHICH REMAINS TO�BE�TAKEN (Bywhomandwhen)� __---- <br /> -------------------------------------------------------------------------- <br /> NAME OF SUPERVISOR TITLE <br /> r- <br /> SIGNATURE DATE <br /> ----_.--------------------------------------------------------------------- <br /> F; <br /> u� <br /> - 30 - <br />