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NEW HIRE CHECK LIST

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NEW HIRE CHECK LIST Powered By Docstoc
					                                   EMPLOYEE INCIDENT –
                                   1ST NOTICE OF INJURY

Name             _______________________________                        Position          ______________________

Department       _______________________________                        Supervisor        ______________________

Employment Date           _________________________                     Social Security # ____________________

Home Address:______________________________________________________________________

Home Phone # _______________________________                            Date of Birth _______________________

Date of Incident          _________________________                     Time of Incident ____________________

Place of Incident         ________________________                      Date Incident Reported _______________

Description of Incident             __________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Name of Witness(es) ________________________________________________________________

Indicate body part affected or injured                ______________________________________________

Describe nature of injury or exposure                 ______________________________________________

Personal Protective Equipment Used                    ______________________________________________

Action Taken in Response to Incident                  ______________________________________________

__________________________________________________________________________________

Action Taken to Prevent Reoccurrence of Incident ________________________________________

__________________________________________________________________________________

Incident Report Prepared by __________________________________                            Date     ________________
                                    (Print Name)

For Human Resources Use Only
Work. Comp. Claim Filed? Yes No            Date Filed    ____________________________
Claim #________________________            Lost Time Injury?   Yes No
Follow up from Incident  __________________________________________________________
___________________________________________________________________________________________________________________________

				
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