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    21 views1 page

    201611231029

    Uploaded by

    api-329355753

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    : a ay, TOSS91ESO1 ! Oct. 15. 014 7:54AM OSH 763-391-85101 p Ne. 2631 i RS" EMPLOYEE WORKPLACE INJURY REPORT — _ .NolerArespgnise'tp allquestions te required: Aniincomiplste to;mhicould tasyt ina desey.n precesIne'this report. CALL 911 IF YOUR INJURY IS A LIFE THREATENING EMERGENCY. mu) ee, | NAME 1. EMPLOYEE NUMBER: = at 2 DATE OFIwuRE) Fe UTES SRR —— NE OF WLR Bhi ___[stacnjeorwomearn 7 BAL TIINSIDE ROOM: OuTSIOE AREAL NAME OF BUILDING WHERE INJURY OCCURED: Location: GOTHER appress: DESCRIBE SPECIFICALLY WHAT YOU WERE DOING WHEN THE INJURY OCCURRED. INCLUDE DETAILS ABOUT YOUR ACTIVITIES/TASKS, WORK LOCATION, ETC. AT-THE TIME OF INJURY! DESCRIBE THE TOOLS, ECUIPMENT, MACHINES, OBJECTS OR SUBSTANCES THAT WERE INVOLVED? \ i A f | ee re ies ee a AN i \ ViROLE THE DRGHAN TO WHERE THE NDUR es) SopURRED iN Mt WASFRSTAD ADMINISTERED? —~—EYS [ore | 7 ay Won Di YOU GOTO THE HOSPITAL? Bye owe: | 77 HOSPITAL NAME DID YOU GOTO THE CLINIC? Cys owe | ys CCuINiC Name: SIR YOU RECEIVE Any OTHER Bw lore FACILITY NAME: [[S0,You ireno T0 Se5

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