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Box _______________________________________________ City State Zip Code County       Job Title _______________________________________ Status: % Faculty % Staff % Student % VisitorWas employee doing his / her regular job?PPE required % Yes % No Issued % Yes % No Used % Yes % No % Part-Time % Full Time % TemporaryDate HiredLength of service in current positionLength of service in occupationCause of injury (slip, fall, machinery, equipment etc.)Witness statements obtained % Yes % No Police notified % Yes % No Risk Management not24 z | Ǽo`oQJQo9 hh0CJOJQJ^JaJ hh0hh0CJOJQJ^Jhh^$CJOJQJ^J hh^$CJ OJQJ^JaJhh0CJOJQJ^Jhh^$CJOJQJ^Jhh&CJOJQJ^Jhh&CJOJQJ^Jh0h&OJQJh0hCJOJQJhh&OJQJhh^P5CJOJQJ^Jhh&5CJOJQJ^J4 : < F P z $$Ifa$gd $Ifgd& $Ifgd0 $Ifgd^$ $$Ifa$gd $$Ifa$gdgd&$a$gd&$a$gd0z |   * J>>55 $Ifgd0 $$Ifa$gdkd$$Iflr|, n(v&& t0+44 layt   @ B b l n  0 < @ B n p r ᄋިިthhSWRCJOJQJ^JhhVCJOJQJ^J hh&hh^$CJOJQJ^Jhh&CJOJQJ^J hh0hh0CJOJQJ^J hh0CJOJQJ^JaJ hh^$CJ OJQJ^JaJ hh0CJOJQJ^JaJ(* @ B D > @ RE<E $Ifgd0 $If^gdkd$$Ifl\|,n(bpp t0+44 layt $Ifgd&@ B n p r    $Ifgd& $$Ifa$gdkkdB$$Ifl|n(+ t0+44 layt    M P  ! ӽӽӽӱӱӱӱӌ{j{ hhVCJOJQJ^JaJ hh^$CJOJQJ^JaJhv~5hv~5CJOJQJ^J hhSWRhhv~5CJOJQJ^JhSWRCJOJQJ^JhhVCJOJQJ^J hh0hhSWRCJOJQJ^JhhMzCJOJQJ^JhhSWRCJOJQJ^J"   ! 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