ࡱ> JLI` bjbjss *}@@@@lllDDD8|@L&" .|~~~I,?$BhlD?l666?@@?6j@l|6|^l I1xD^8D?0@EEEl$6666666??j666@6666DD@@@@@@  Accident/Incident Report Form Date of incident: _______________ Time: ________ AM/PM Name of injured person: Address: Phone Number(s): Date of birth: ________________ Male ______ Female _______ Type of injury: Details of incident: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Witnesses/Employees Who Assisted: _______________________________________________ Injury requires physician/hospital visit? Yes ___ No _____ Name of physician/hospital: Address: Physician/hospital phone number: Result from Physician/hospital visit: ________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Signature of injured party _________________________________________________________ Date *No medical attention was desired and/or required. Signature of injured party Date      DATE \@ "MM/dd/yy" 09/21/11  FILENAME Accident-Incident Report Form 3  PAGE 1/ NUMPAGES 1  u " H c n x @A /089>?ɿԿ߿{mjhHOJQJUhhz[eOJQJmHnHuhHOJQJjhHOJQJUhHjhHUhz[ehz[eCJOJQJh|HCJOJQJhz[eCJOJQJhz[e>*CJOJQJhH>*CJOJQJhHCJOJQJhH5CJOJQJhz[e5CJOJQJ* !"[\ H F n  AB x^ $x^a$ $^a$$a$  % $^a$gdz[e $x^a$?IJijopvwxyz{˲ˣ˛hz[eCJOJQJhHhHOJQJhH0JOJQJmHnHuh|H0JOJQJmHnHuhH0JOJQJjhH0JOJQJUhHOJQJhmHnHujhHOJQJUhhHOJQJh(/ =!"#$% 08@8 Normal_HmH sH tH Z@Z Heading 1$  %:CJ$KHOJQJkHN@N Heading 2 $` ^` 5CJOJQJkHB@B Heading 3 $<5CJDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List RB@R Body Text$@ d^@ a$ OJQJkHO Bullet$ & F dx>Th^ `a$ OJQJkHO! BulletHead{ & F@ <x>Thn@& ^@ `5CJOJQJkHO" BulletTexth & F>T`@ @2@ Footer   %CJOJQJkHZ@BZ Header$ ! h] a$5CJ<OJQJkHHORH Number $-Da$56CJHOJQJkH:O!b: NumList0^0`>Or> Table ddCJOJQJkHBOB TableHead5CJOJQJkH.)@. Page NumberO Check1x & F xx>Tho^ `5CJOJQJkHO Check2t & F(x>Thq^(`LOL Comments<^5CJOJQJkHDOD Contents xxCJ OJQJkHROR Contents2  `(^`CJOJQJkHBOB Line$ D%d^a$5:O: Sidebar CJOJQJkHO TOC! & F $ hx>T hn]^h`CJOJQJkH(O"( TOC2"DO2D TOCHead #$ha$CJHOJQJkHDOBD Policy2$$ $ OJQJkHO!R BulletTxt2p% & F>Th^`VObV Contents1&   (^ 5CJOJQJkHOr Policy1' & F H$>T^`CJOJQJkH6OA6 Policy3 ( 4O4 Policy4 ) 4O4 Policy5 *$a$<Oq< Spacer+-D HCJ.O. BTLeft,$a$O Policy Bullet-$ & F h>Th𷷷^h`a$O Policy Dashv.$ & F>Th-^`a$6O16 TOCHead2/$a$CJ  !"[\ H FnAB00000000000000000000000000h0Mh0h0Mh0h0Mh0h0Mh0@0h0h0t#h0 |||?   !*0;[ahjlwy!accident_report  G @  oyz |Hz[eHx@RICOH Aficio MP C4500 PCL 5cNe01:winspoolRICOH Aficio MP C4500 PCL 5cRICOH Aficio MP C4500 PCL 5c  odXXLetter (8.5" x 11")RICOH Aficio MP C4500 PCL 5cLPT1:NADC@ K( d''''d o dDefaultRICOH Aficio MP C4500 PCL 5c  odXXLetter (8.5" x 11")RICOH Aficio MP C4500 PCL 5cLPT1:NADC@ K( d''''d o dDefault  w  `@UnknownGz Times New Roman5Symbol3& z Arial=Don CasualI"Helvetica-Narrow;Souvienne;Wingdings7Tms Rmn"h f"f] x   !4  2QHP ?z[e2%SAMPLE INCIDENT/ACCIDENT REPORT FORM Katie McDermottDACCOh+'0 $ D P \ ht|(SAMPLE INCIDENT/ACCIDENT REPORT FORM Katie McDermottNormalDACC3Microsoft Office Word@@~ZX@H^x@,x ՜.+,0 hp  NC DOT   &SAMPLE INCIDENT/ACCIDENT REPORT FORM Title  !"#$%&'()*+,-./012345678:;<=>?@BCDEFGHKRoot Entry F[2xMData 1TableEWordDocument*SummaryInformation(9DocumentSummaryInformation8ACompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q