| 1. EVENT TYPE : |
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| * Type of event : |
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| * Date of event (mm/dd/yyyy) : |
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| * Time (hh : mm) |
:
am
pm
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| * Brief Description of event / hazard : |
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| If any corrective measures have been taken or required, please explain : |
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| 2. VICTIM OR COMPLAINANT INFORMATION : |
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| * Family Name : |
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| * First Name : |
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| Age : |
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| Home telephone : |
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| Office telephone : |
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| Email : |
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| Sex : |
Male
Female
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| ID # : |
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| * Status : (At the time of event) |
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| * Department : |
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| Supervisor (if applicable) : |
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| Union/Association (if applicable) : |
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| 3. EVENT LOCATION : |
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| * Campus : |
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| * Building : |
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| * Room Number : |
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| Location : |
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| 3. INJURY : |
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| Type of Injury : |
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| Body Part Injured : |
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| Type of treatment : |
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| Transportation recommended : |
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| * Transportation Refused : |
Yes
No
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| If Yes, state reason : |
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| Employees only: Consequence of Injury (check one) : |
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| If there was time loss from work, please indicate how long (in days) : |
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