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Injury/Illness Report <br />CORRECTIVE ACTION(s) REQUIRED: <br />ASSIGNED TO: <br />Signatures: <br />Direct Manager/ Supervisor <br />Health & Safety Manager <br />Human Resources <br />Date <br />Date <br />Date <br />Section 4 - To be filled out by Health and Safety Manager, <br />Accident, Illness, Incident Classification: <br />Injury/Illness Severity: OSHA Illness Code: <br />? First Aid Only ? Occupational Skin Diseases or Disorders <br />? Medical Treatment ? Dust Diseases of the Lungs <br />? Lost Workdays - Restricted Activity ? Respiratory Conditions Due to Toxic Agents <br />? Lost Workdays - Away from Work ? Poisoning <br />? Fatality Date: ? Disorders Due to Physical Agents <br />? Total Number of Lost Days: ? Disorders Associated with Repeated 't'rauma <br /> ? All Other Occupational Illnesses <br />For Office Use Only: <br />Case Nos. of Others Injured, Ill, or Involved in the Same Accident: <br />Case No.: OSHA Recordable? Yes - No <br />Region: Address: <br />Project No.: Accident or Diagnosis Date: <br />Health And Safety Program <br />A-6 <br />19E-37