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Employee Report of Injury

Employee's full name
Employee's home address
(examples: Laceration to left hand, strain to lower back)
(indicate right or left side if applicable)
What were you doing when the accident occurred? (Please describe fully, and include details about materials, equipment or other people involve.)
Were there any contributing factors? (describe fully the events which resulted in the injury)
Witness 2

By clicking submit, I certify that to the best of my knowledge the information provided above is true and accurate.