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2014
January
I
Injury Report
Injury Report
0%
Questions marked with an
*
are required
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*
First Name
:
*
Last Name
:
*
Phone
:
*
Email Address
:
Preferred method of contact?
Phone
Text
Email
- Date of Injury -
--
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Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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2024
Location and type of injury (Example: right broken ankle):
Crew member(s) involved:
Where did this injury take place?
Zone Office
Warehouse
Event Location
Other
Please specify all pieces of equipment and/or materials being used at time of injury:
Detailed description on how injury occurred:
Was the injury treated?
Yes
No
Was the crew member(s) hospitalized?
Yes
No
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