Police Information Only Injuries
Your Name
*
First Name
Last Name
Age
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Sex
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Please Select
Male
Female
Job position/title
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Last 4 digits of Social Security Number
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Supervisor
*
Supervisor's Email Address
*
Don't know their email? Copy and paste URL for list email addresses: http://employee.spanishfork.org/empDocs/employeeDirectory.php
Date and time of Accident
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Month
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Day
Year
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Hour
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Minutes
AM
PM
AM/PM Option
Location
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Task being performed when accident occurred
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Date-time accident reported
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Accident reported to whom?
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Date-time accident was reported to you
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Full Name(s) of Witness(es)
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First aid given?
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Yes
No
Describe how the accident occurred
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What part of the body was injured?
*
Describe the injuries in detail
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Could anything have been done to prevent this accident? If so, what?
*
Signature
*
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