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Injury/Illness Report <br />Section 1- To be completed by Employee. <br />Information about Injured, Ill, or Involved Employee: <br />First Name: <br />Last Name: <br />SSN: <br />Employee Number: <br />Name of Firm: <br />Address and Phone No.: <br />Employment Category: <br />Regular Full time <br />L Regular Part time <br />Temporary <br />Ll Non-employee <br />Length of Employment: <br />In training 1 3-5 years <br />l <6 months 5-10 years <br />L 6 mos-1 yr 10-20 years <br />L 1-3 years 20+ years <br />Time in Occupation: <br />In training L 3-5 years <br />C: <6 months 5-10 years <br />7 6 mo-1 yr LI 10-20 years <br />1-3 years L1 20+ years <br />Section 2 - To be completed by Employee. <br />Information about Accident/lujur /Illness: <br />Date of Accident/Incident <br />Specific Location of Accident/Incident: <br />Witness(es) to the Accident/Incident: <br />Employee's Usual Occupation: <br />Occupation at Time of Accident/Incident: <br />Direct Manager /Supervisor <br />Injury or Illness? Injury Illness <br />Property Damage? 1 Yes No <br />Vehicle Involved? Yes No <br />Phase of Employee's Workday at Time of Injury: <br />L Performing Work Duties L During Meals <br />Entering or Leaving Workplace C Other <br />Health And Safety Program <br />Middle Initial: <br />Sex: I M I F Age: <br />Time: <br />During Rest Period <br />A-1 <br />19E-32