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C <br />SUPERVISOR'S REPORT OF ACCIDENT <br />Employee's name Social Security # <br />Job position/title Supervisor's name <br />Date and time of accident Location <br />Task being performed when accident occurred <br />Date and time accident reported to you <br />Name(s) of witness(es) <br />Accident resulted in: InjuryFatality_ Property Damage_ <br />First aid given?_ Medical treatment required?_ Workdays lost?_ <br />Describe how the accident occurred <br />What actions, events or conditions contributed most directly to this accident <br />Could anything be done to prevent accidents of this type?� If so, what? <br />Signature of supervisor Date <br />