Incident Report Employer'S Report On Medical-Only Injury Michigan Employees - Kellogg Community College Page 2

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KCC Incident Report
Section 1. Employee Identification
Injured Employee Name (please print)
Date of Accident
Section 2. Injured Employee's Statement
(Employee's Signature)
Section 3. Witness Statement
Name of Witness (please print)
(Witness' Signature)
Section 4. Corrective Measures to be completed by Supervisor
Measures implemented to prevent a recurrence of the accident
Completed by
Date
Corrective Measures Implemented by
Date Corrective Measures implemented
Verification of implementation by
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