Injury Report Form
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1
2Injury Report
Employee Name
Department
Title
Age
Sex
Date of Injury
Time of Injury
Did the injury occur while performing a work related activity?
Describe the injury. What body parts were affected? What kind of injury?
Describe what was happening when the injury occurred.
Was any first aid given at the scene? If so, what type?
Were there any witnesses? If so, please provide their names.
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Parent category: Business