All questions should be answered so a complete investigation can be made and the employee can be counseled on how to prevent the accident from occurring in the future. A copy of this form is found in Exhibit III with the numbers corresponding to the instruction below. Use ballpoint pen or typewriter. View Exhibit III in Adobe Acrobat format.
Instructions Enter injured employee's name.
Enter injured employee's social security number. Enter injured employee's age. Enter injured employee's gender. Enter injured employee's job title. Enter the injured employee's date of employment.