ࡱ> <>;]  bjbj~]~] .47i7i#####7777$[,7;.bbb$il#bbbbb##RRRb##RbRRR`=xR 0;RNR#RTbbRbbbbbbbb;bbbbbbbbbbbbbY : INCIDENT REPORT (Please Answer Every Question) Employee Status: RSHD______ SFE______ KELLY______ THE BUDD GROUP______ SCECG______ Your Name: ____________________________________________________________________ First Middle Last Your Employers Name and Location:___________________________________________________ Your Address: ___________________________________________________________________ Street City State Zip Telephone Number: _________________ Social Security: ________________ Age: _________ Date of Birth: ___________ Job Title: ___________________ Length of Employ: ___________ Date of Injury: __________ Time of Injury: ________am ________pm Describe how you were injured: _____________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Describe the type of injury (ex. bruise, contusion, strain, sprain, etc.)________________________ _______________________________________________________________________________ Did your injury occur from one specific incident? ______ If yes, explain in detail. _____________ _______________________________________________________________________________ _______________________________________________________________________________ Did your injury develop gradually over a period of time? _______ If yes, indicate period of time: From: ______ ______ To: ______ ______ Describe how injury developed. ____________ Date Time Date Time _______________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Is there any way, other than described above, that you possibly could have injured yourself? Yes ____ No ____ If so, please give details. ________________________________________________________________________________ ________________________________________________________________________________ Explain what caused your injury: (Example: What caused you to fall). ______________________ ________________________________________________________________________________ ________________________________________________________________________________ If you were lifting or moving an object when you were injured, describe the object: _____________ ________________________________________________________________________________ Give the approximate weight of the object: ___________________ Incident Report Page 2: Describe the position you were in when you were injured: (Example: Sitting, Standing, Squatting, Bending). ________________________________________________________________________________ ________________________________________________________________________________ When did you first realize you were injured? _________ _______ . When did you first feel the Date Time pain? ________ ________ Who at work, did you first tell about your injury? ______________ Date Time _____________________________ When did you tell them? _______ _______ . When did you Date Time first tell your immediate supervisor of your injury? _______ _______ . Name of your supervisor Date Time you reported your injury to: _________________________________ . If injury was not reported to your supervisor on the date you were injured, state the reason it was not reported: ___________ _________________________________________________________________________________ Name(s) of person(s) who witnessed your injury: _________________________________________ List parts of your body injured: _______________________________________________________ List type of injury (ex. bruise, contusion, strain, sprain)_____________________________________ Names & Addresses of Physician(s) who have treated you for this injury: _________________________________________________________________________________ _________________________________________________________________________________ Name & Address of Hospital: __________________________________________________________ _________________________________________________________________________________ Have you lost time from work due to this injury? ___ ___ If so, indicate the first day you missed from Yes No work? _____________ If so, indicate the date you returned to work after this injury? ___________ Additional Remarks: ______________________________________________________________ _________________________________________________________________________________ * I certify that the answers given to the questions on both pages (2) of this Incident Report are correct and accurate to the best of my ability and recollection. _____________________________________________ ____________________________ Employee Signature Date Rev. 05/2020 Please send report to Katrina Lanzer, District Office  %01BLNWYdefjmz{|f g {  3  Ӷ|qgg\gghn5CJOJQJhqCJOJQJhR'5CJOJQJhf5CJOJQJaJhThR'5CJOJQJaJh %5CJOJQJaJhThT5CJOJQJaJhT5CJOJQJ"hl hq5>*CJOJQJaJhl hq5CJOJQJaJhq5CJOJQJ"hThq5>*CJOJQJaJ$01f g    h i 4 5 @&gd9EgdR'gdT$a$gdT$a$gdl $a$ $@&a$gd9E  h i 4 5 9 : BCe_`&[^ef   no   $%&auvhq5>*CJOJQJhT5CJOJQJhq5CJOJQJhq5CJOJQJ hq5CJhqCJOJQJ hqCJhq5CJOJQJE 9 : BCe_`&^e@&gd9Eef   no   $%&89@&gd9E789jktu"#uv!"tuGHuhq5>*CJOJQJhqCJOJQJhq5CJOJQJhq5>*CJOJQJhqCJOJQJhq5CJOJQJ hqCJhq5CJOJQJ>jktu"#uv!"t@&gd9EtuGHWX  d $@&a$gdn@&gd9EWX  d    ȽhFb5>*CJOJQJaJ"hnhn5>*CJOJQJaJhn5CJOJQJhM_5CJOJQJhl 5CJOJQJhq5CJOJQJhq5CJOJQJhq5CJOJQJ,1h/ =!"#$% x2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List ZYZ 9E Document Map-D M CJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V (BO)MBT.$@0H!A>풠Uc-zD[&!rX=}zC0` ި%.]Ssd--7 +fOZեrŵVœ\lji2ZGwm-3˵j7\ Uk5FҨ-:xRkcr3Ϣ+9kji9OP Et-j|#p;E=Ɖ5Z2sgF=8 K}*7c<`*HJTcB<{Jc]\ Ҡk=ti"MGfIw&9ql> $>HmPd{(6%z:"'/f7w0qBcF6f Iöi1(\}B5ҹ~Bcr6I;}mY/lIz1!) ac 1fm ƪN^I77yrJ'd$s<{uC>== Ƌ(uX=WA NC2>GK<(C,ݖm: &-8j^N܀ݑ$4:/x vTu>*ٞn{M.Ǿ0v4<1>&ⶏVn.B>1CḑOk!#;Ҍ}$pQ˙y')fY?u \$/1d8*ZI$G#d\,{uk<$:lWV j^ZơSc*+ESa1똀 k3Ģxzjv3,jZU3@jWu;z \v5i?{8&==ϘNX1?  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