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Tho is an official document to be milk by the employee's supervisor. Pieria answer questions completey. This report must be <br /> forwarded to the Group Hearth and Sip* office within 24 houn Of the y or I0cider000 <br /> Sex S.S. No. Birthdate _ <br /> Injured'• Name State ZipPhone�---- <br /> Horne Address Hire Dale Houry Wage <br /> Job Title Employee's P,C. <br /> SUPERVISOR <br /> Date a Incident Tine Time reported To WhOm? <br /> Client nae Client address Time shlff began <br /> m <br /> Exact location of Incident Did employee leave work? No Yes When <br /> Has employee relumed to work? No Yes When <br /> Did employee miss a reguiary scheduled$11M after the day of the incident? No Yeo <br /> Nature of injury Exact body Pall <br /> Medical Attention: None First aid on site Doctoes office Hospital ER Hospilaiized <br /> Job assignment at time of Incident Project_ Task Subtask <br /> Descrttae Incident <br /> What unsafe physical condition or unsafe act caused the Incident? <br /> What correcttve action has been taken to prevent recurrence? <br /> Supervisor <br /> (PrInt) Signature Data <br /> MANAGER <br /> Corturwft on Incident and corrective action <br /> Manager's name <br /> tp" Signature Date <br /> HEALTH AND SAFETY <br /> Concw with action taken? _ No Yes Remarks <br /> OSHA Ci MNICation: <br /> Incident only _First aid No iost workdays Lost workdays Restricted activity Fatality <br /> Days away from work Days restricted work Total days charged <br /> Coding: Al Injury type or Inness____ B. injured body parts_ C. Activity at time d accident_ D. Injury cause code_ <br /> E. Agent code_ F. Safety rule violated code G. Accident prevention code , <br /> Name <br /> (Prw) Signature Date <br /> White:Group Health and Solely Yellow:Corporate Insurance Pink: Businaaa Unit Manager <br /> h*Tp CC: General Counsers Office It accident Involves death,serious injury or substardial property damage. <br />