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Injury/Illness Report <br />General Type of Task Being Performed at Time of Injury/Illness: <br />Specific Activity Being Performed at Time of Injury/Illness: <br />Employee Was Working: <br />Alone With a Crew or Fellow Worker I Other Crew size: <br />Supervision at Time of Accident: <br />11 Directly Supervised ? Indirectly Supervised 11, Not Supervised L Supervision Not Feasible <br />Description of Accident: <br />Recommendations for Corrective Actions: <br />Name, Address, and Phone Number of Attending Physician (If Applicable): <br />Name and Address of Hospital: <br />Description of first aid or medical treatment provided to injured employee: <br />Health And Safety Program <br />A-2 <br />19E-33