minim Cans-mum cm; Slall arc. nil MINOR INJURY REPORT cc: 35(fiwiflfl mm I .s I Lui digiis nl SSN: Dale of Elnh: Empl en's Mama: wm/ J/me/A Sammie/Uni? CIMIficalinn: Pmiem Code: [7445 {retina Dal: 01 Time Ocmrred: Date of Employers KnaMadgs al 2/1/16 "mg/My #15714." Spa-cm: Injury/Illness]: Fan Buoy: acfiviry a! lime I11 injurylillness: l7, film/Q4, (Au-7 only JV Describe Iwwinjuiy nr iilness 12mm 1/9" (by (M14 <<10/9 t/fed a" 01-7 fig/1m! a} o/uf fa [am My). flowii' w/ A my, 5/901 S0 5 am (/uv Jug>>, as 04V- 4/1 claw W, AidTmalment idea? 4996' Win! can-diva am is king taken in prevunl similar accidents/injuries: Wk? inforwj WK do" [5 ecu (Q VVhal was me mpiqs) of [ha Tailgate Safety mesling an 015 we onnguiy: \Mlne Mm [w I: p, a Emma '5 Signalu Dale. 2/2. Supervisurs Name/Tile (Piimy Supervisor's Signaium: Dale. IMEQETANT NOYE: The CDC 1! i: ONLY when then is medical (rallmeul of last work um: beyond me an: or injury/Illness, muise. scrape, minar cm. unison m. minor slrairilspraln, etc. and employs: chooses In seek medical anemia . (SEE FOR ADDITIONAL INFORMATION AND REQUIRED ACTION)