Form 1 - State Of Delaware First Report Of Occupational Injury Or Disease Page 4

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5. Was the accident the result of failing to wear personal protective equipment? (Explain)
6. What corrective action(s) has been or will be taken to prevent a recurrence of this type of accident (repair/modify/replace equipment, counseling,
training, policies, procedures, etc.)?
7.
Who is responsible to implement correction actions?
INVESTIGATED BY:
DATE:
REVIEWED BY:
DATE:
Safety Committee Chair
Supervisor
ENVIRONMENTAL HEATH & SAFETY USE ONLY
Routing:1. Supervisor, 2. Safety Chair, 3. Environmental Health and Safety, 4. Labor Relations

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