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OMB approval expires 02/28/2014 |
SHEET ___ OF ___ |
4. Report Year |
5a. |
Accident/Injury Number |
5b. |
Day |
5c. |
Time |
of Day |
5d. |
County |
5e. |
State |
5f. |
Type |
Person/ |
Job Code |
5g. |
Age |
5h. |
Drug/ |
Alcohol Test |
A D |
5i. |
Injury |
Illness |
Code |
5j. |
Physical |
Act |
5k. |
Location |
5l. |
Event |
5m. |
Tools |
5n. |
Cause |
5o. |
Number of |
Days Away |
From Work |
5p. |
Number of |
Days |
Restricted |
5r. |
Special Case |
Codes |
5q. |
Exposure to |
Hazmat |
5s. Latitude |
5u. Narrative (Up to 250 Characters) |
5t. Longitude |
5a. |
Accident/Injury Number |
5b. |
Day |
5c. |
Time |
of Day |
5d. |
County |
5e. |
State |
5f. |
Type |
Person/ |
Job Code |
5g. |
Age |
5h. |
Drug/ |
Alcohol Test |
A D |
5i. |
Injury |
Illness |
Code |
5j. |
Physical |
Act |
5k. |
Location |
5l. |
Event |
5m. |
Tools |
5n. |
Cause |
5o. |
Number of |
Days Away |
From Work |
5p. |
Number of |
Days |
Restricted |
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