ࡱ> NPMO 5bjbj@@ 4B"e"e;Gnn8y yyyyT `T$#"$QXTTXXyy3 888XFyy8X888yPqgR8I 0y 8%B%8%8pXX8XXXXX2XXXy XXXX%XXXXXXXXXn y: Injured Employee s name:  FORMTEXT       Name of witness:  FORMTEXT       Job title of witness:  FORMTEXT       If applicable, years employed here:  FORMTEXT      Witness department:  FORMTEXT       Extension:  FORMTEXT       Home address of witness:  FORMTEXT       Witness home phone:  FORMTEXT       Date of incident:  FORMTEXT       Time of event:  FORMTEXT       (AM/PM)  FORMCHECKBOX  Check if time cannot be determined Where did the incident occur? Building or area:  FORMTEXT       Room number (if applicable): FORMTEXT       Location Detail (pinpoint where accident occurred-  Near water fountain or  at dumpster ):  FORMTEXT       Name of your supervisor:  FORMTEXT       Extension:  FORMTEXT       What was the employee doing immediately before the incident occurred? Describe the activity, as well as the tools, equipment or materials they were using. Be specific. Example:  climbing a ladder while carrying roofing materials  FORMTEXT        FORMTEXT       What happened? Tell us how the injury occurred. Examples:  When ladder slipped on wet floor, worker fell 20 feet; worker developed soreness in wrist over time.  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Tell us the area or part of the body that was affected. Example: burn on right forearm. Include, if applicable, any symptoms. Examples: fainting, dizziness, blurred vision)  FORMTEXT        FORMTEXT       What object or substance directly harmed the employee? Example:  concrete floor ; if this question does not apply, leave it blank.  FORMTEXT       Recommendation on how to prevent this accident from repeating:  FORMTEXT        FORMTEXT       Witness signature: Date:  FORMTEXT           Witness Incident Report (Please print legibly) When form is complete, fax to (X82228) and mail to Environmental Safety, MB 120A or email Jillian Townsend, jetownsend@salisbury.edu. Questions about completing this form? 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