1. Injury Incident Report

    Case Information

  2. Company(*)
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  3. Event Date(*)
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  4. Time(*)
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  5. Location(*)
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  6. Brief Summary(*)
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  7. Include, if applicable, any contributing factors; the initial response; source/equipment involved; the pollutants/contaminates released; measured or estimated quantities applicable permit limits; operational conditions prior to, during and after the incident; and actual/potential environmental impacts.
  8. Detailed Description(*)
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  9.  
  1. Employee Information

  2. First Name(*)
    Please type your full name.
  3. Last Name(*)
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  4. Supervisor Name(*)
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  5. Date of Birth(*)
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    MM/DD/YYYY
  6. Gender(*)
  7. E-mail(*)
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  8. Job Title(*)
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  9. Time Employee Began Work(*)
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  10. Time of Injury(*)
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  11. Date Employer Notified
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  12. Date Employee Returned to Work
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  13.  
  1. Accident Information

  2. Primary Type of Injury(*)
    Please tell us how big is your company.
  3. Secondary Type of Injury
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  4. Primary Body Parts Affected
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  5. Secondary Body Parts Affected
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  6. Primary Cause of Injury
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  7. Secondary Cause of Injury
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  8. Did injury occur on employer's premises?
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  9. Were safeguards provided?
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  10. Were safeguards used?
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  11. Employee's Initial Treatment
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  12.  
  1. Medical Information

  2. Physician/ Health Care Provider(*)
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  3. Hospital Name(*)
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  4. Address(*)
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  5. City, State, Zip
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  6. Hospital Overnight?
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  7.  
  1. Contact/Agency/Witness Information (Optional)

  2. Contact Type
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  3. First Name
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  4. Last Name
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  5. Title
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  6. Company/Agency Name
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  7. Phone
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  8. Email
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  9. Notes
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  10. Attach Photo 1
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    .jpg (image file)
  11. Attach Photo 2
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    .jpg
  12. Attach Photo 3
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    .jpg
  13. Attach Photo 5
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    .jpg
  14. Attach Photo 4
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    .jpg
  15. (*)
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    Please type the number you see in the box
  16.