Accident Incident Report
ADA
General Inquiry
Grievances
Workers Compensation
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Employee Name
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Employee Job Title
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Email Address
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Phone Number
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Team
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Country/State
Mexico
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Air Force Europe
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Manager Name
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Manager Phone Number
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Date Of Injury or onset of illness
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Time of injury illness
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What were the Body Part(s) Affected?
Abdomen
Ankle(s)
Arm(s) and Forearm(s)
Back (lower)
Back (upper)
Chest, including ribs, internal organs
Ear(s)
Elbow(s)
Face
Finger(s)
Foot (Feet), Except Toe(s)
Genitalia
Hand(s), Except Finger(s) and Wrist(s)
Head, Cranial Region Including Skull
Hip, Pelvic Region
Knee(s)
Leg(s)
Multiple Body Parts
Neck
Prosthetic Devices
Shoulder, Including Clavicle, Scapula
Toe(s)
Unknown
Wrist(s)
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Incident Type?
(1) Injury
(2) Skin Disorder
(3) Respiratory Condition
(4) Poisoning
(5) Hearing Loss
(6) All Other Illness
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Description
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Required Field
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