Document vJ8O9MpwNkyN2Qr2429R5Lm

REPORT OF MINOR INJURY SECTION * 1 EMPLOYEE NAME: DEPT.# PLOYEE JOB TITLE: T5HHIEN EMPLOYEE CAME FOR TREATMENT. DATE: DATE OF INJURY: _______ TIME: A. M. P.M. TIME: IS TREATMENT NECESSARY? (IF SO, STATE NATURE OF INJURY AND INCLUDE EMPLOYEE'S STATEMENT.) A.M. P.M. TREATMENT ADMINISTERED: EMPLOYEE SENT: WORK____ HOME_ EMPLOYEE SIGNATURE:____________ FIRST AIDER SIGNATURE:________ DOCTOR HOSPITAL -------------(IF SENT TO DOCTOR OR HOSPITAL, INDICATE NJBE'.T COPY TO LEftD TECH/ALLIED SUPERVISOR SECT ION t-E^P TECH/ALLIED SUPERVISOR LEAD TECH/ALLIED SUPERVISOR REMARKS & CORRECTIVE ACTION: LEAD TECH/ALLIED SUPERVISOR SIGNATURE: SECT X OfNi 4!3 AREA MANAGER AREA MANAGER REMARKS: W^NAGER SIGNATURE: CTL019882 JSS-063 RETURN 5-11-87 TO SAFETY DEPARTMENT