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 WC 1 Department of Labor and Industrial Relations 2003

WC 1 Department of Labor and Industrial Relations 2003

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WHY POLICY NO. Tell what happened. Please use separate sheet if necessary SOURCE OF INJURY INDUSTRIAL CODE NO EVENT TIME WORKSHIFT BEGAN WHAT WAS EMPLOYEE DOING WHEN INJURED ON EMPLOYER S PREMISES Please be specific. Identify tools equipment or material the employee was using ACTIVITY TASK ACCIDENT FACTOR AOS OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE e.g. the machine employee struck against or struck him the vapor or poison inhaled or swallowed the chemical that irritated his skin. In...
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