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Mailing Address: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\fs16\insrsid13531860 \tab \tab (Street) (City) (State) (Zip) \par \par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 3. Daytime Telephone Number: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 4. Evening Telephone Number: }{ \rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par 5. }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid8153420 Controlling }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 Dept/Agency where injury occurred: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab \tab \tab }{ \rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par \par 6. Date of Injury: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 7. Time of Injury: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab }{ \rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par \par {\pntext\pard\plain\ltrpar \s16 \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \insrsid13531860 \hich\af0\dbch\af0\loch\f0 8.\tab}}\pard \ltrpar\s16\ql \fi-360\li360\ri0\widctlpar\jclisttab\tx270\wrapdefault{\*\pn \pnlvlbody\ilvl0\ls9\pnrnot0 \pndec\pnstart8\pnindent360\pnsp120\pnhang {\pntxta .}}\aspalpha\aspnum\faauto\ls9\adjustright\rin0\lin360\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 Where Injury Occurred: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \par }\pard \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault{\*\pn \pnlvlcont\ilvl0\ls0\pnrnot0\pndec }\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid8153420 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\fs20\insrsid8153420 \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\fs20\insrsid13531860 (}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\fs20\insrsid8153420 address}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\fs20\insrsid9862263 , city & state}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\fs20\insrsid13531860 )}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\fs20\ul\insrsid13531860 \par }\pard \ltrpar\s16\ql \fi720\li2160\ri0\widctlpar\wrapdefault{\*\pn \pnlvlcont\ilvl0\ls0\pnrnot0\pndec }\aspalpha\aspnum\faauto\adjustright\rin0\lin2160\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\fs20\insrsid13531860 . \par {\pntext\pard\plain\ltrpar \s16 \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \insrsid13531860 \hich\af0\dbch\af0\loch\f0 9.\tab}}\pard \ltrpar\s16\ql \fi-360\li360\ri0\widctlpar\tx270\jclisttab\tx360\wrapdefault{\*\pn \pnlvlbody\ilvl0\ls9\pnrnot0 \pndec\pnstart8\pnindent360\pnsp120\pnhang {\pntxta .}}\aspalpha\aspnum\faauto\ls9\adjustright\rin0\lin360\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 Describe fully }{\rtlch\fcs1 \af0 \ltrch\fcs0 \i\ul\insrsid13531860\charrsid9862263 what}{ \rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 injury occurred (mention body part(s) affected) and explain }{\rtlch\fcs1 \af0 \ltrch\fcs0 \i\ul\insrsid13531860\charrsid9862263 how}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid9862263 and exactly }{\rtlch\fcs1 \af0 \ltrch\fcs0 \i\ul\insrsid9862263\charrsid9862263 where}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid9862263 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 the injury occurred: }{ \rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par }\pard \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par 10. Witnesses to injury: Name: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 Telephone Number:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par \par }\pard \ltrpar\s16\ql \fi-360\li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 11. Injury resulted in what treatment at the site: First Aid }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 Ambulance/paramedics }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 Other, specifically }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par }\pard \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 12. What factors, events and/or conditions contributed to the incident? }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \tab \tab \tab \par 13. Did the customer/visitor express any concern about the incident? Yes }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 No }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par If Yes, what was mentioned:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par \par 14. Name and title of person completing this report: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par }\pard \ltrpar\s16\ql \fi420\li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 Date: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab }{ \rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 Time: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \tab \par }\pard \ltrpar\s16\ql \li420\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin420\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 \par \par Signature: }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 Telephone Number:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \tab \tab \tab \tab }{ \rtlch\fcs1 \af0 \ltrch\fcs0 \b0\insrsid13531860 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\ul\insrsid13531860 \par }}