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Date of Accident: Date of Investigation: Location of Accident: Did Injury Result? Yes/No Social Sec. No.: Describe Type of Injury: Was Property Damaged? Yes/No: Describe damage/owner: If yes, provide Employee Name(s): Yrs. In this Skill: Time of Accident: Job Number: Company: Client:
Skill:
Is damaged property secured/maintained? Yes/No: Names of Witnesses/Co-workers (With Social Security No.)
Person Maintaining: