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Location
First name of injured employee
Last name of injured employee
*
Date of Injury
*
Time of Injury
:
AM
Did the employee see a medical provider?
Yes
No
Position working during injury
Management
SLT
Cook
Prep
Server/Cashier
Driver
Other
Equipment in use or cause (if any)
*
What was the injury (cut, burn etc.)
*
Details of injury and events that caused injury
Was injury handled in the store
Yes
No
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Manager on Duty
*
People who witnessed or could help describe the incident if needed
Submit
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