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Injury Report
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Name
*
First
Last
Date and Time of Injury
*
Date
Time
Time Work Day Began
*
Date
Time
Part of Body Injured
*
Where did the Injury Occur?
*
Address Line 1
City
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Alaska
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District of Columbia
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South Carolina
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Tennessee
Texas
Utah
Vermont
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Wisconsin
Wyoming
State
Was Treatment Received?
*
Yes
No
Detailed Description of What Happened
*
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