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Injury/Tliness/Treatment Form Samana Frat Name Tee 24 Foor Tine >> Date nedert > Type of Accor >be, Personal Protctve Equpment = ‘val om > Fre | tancaiae [nese ‘iewo | Mask Gas [>] ver | No | flectrcty Po] On | of (Chet Corian: [Number of Patients (circle) | = | PasonsVorson of inion Seb EELT Hospial | Seourty Fracture Haemontage Contision Delocation| ume icy Swot ¥ c 8 R s. ‘bing [stra [Sending ‘Aer Respond to Verbal Rescond to Pain Unrcsponsivo Respiration Putse | Rate ‘Sgn and Symp ewe Mean Pesinent Hon vent Leading to ores Gan Tocation Ser Work Ae Face She Te Name Depart Se_[>] ‘eater Come | Sye Guce OK | _ scan Potce Dept _[ Otter Der ‘Rocoina Pin Proten ‘Alergjes & Medical Reacton Breathing Problen/Asthma, ume cardiac Aree (Chest Pain (non raumate) Diabetic Probie Etctcuton Electric Shack Eye Problems Warm, Oy (Cot tary Warm, Moist od Ory Breath Sounds ® R ‘bance Hosp Sent Home Funher Ra Treatment Retwn to Work ‘Chemical Reagent Time Al Clear by 086 Feral Fats Alm T Clare OB Revreatmert Employee | Yes Ne [Bree Fitng Convusing HeauCald exposure OD ingestion Potonings Obstetric Trauma Penetrating Other Non Specie) Cervical Calor Spine Board ‘Scoop Stretcher SKED Manual Posten suction rat Away Nasal Cala Face Mask Non Rebreating Mask Tire Nine [ower [omer

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