REPORT OF WORK- RELATED 

11111
EL (31.111111111111111111 for?r'nm 11.1.5 entirety 1:111:1111111119111/
SAN DHUU SIAM Please fax [0 619'594?4013

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File as: Date of Injury 1 Time of Injury 7

Worker's Compensation Claim a} 8.111. 0 pm.

0 Incident Only Report SUPENUED 1e 51111111111116

?Employee?s; Namo? (1.3111, First) Home. Phone Cell Phone 1* . y?vgrk Phone
. . .111, 
Deoirutmenxt g. .4 f) 13hiame Sumo/1501's Work Phone Supervisor's Email Supervisor's 
11011111110111211 Per Week: DaysWorked: 5 Th Starttime: 0 11.111. End Time: 0 21.111.315; - INFORMATION 1 1
Injured Body Part BACK I-IAMD FRONT OI HAND
1 \kag lcinzlo 11111111er parli 11?11111. 111ml
Type ?of Injury 
{A?Wva 0112,? 
Copb (11? I)

Action Causing Injury ?1 
6111111?me 1 
Contributing Object/Equipment 1r .
(L1 1r GQUQJ U344 Left Right Left 111131111

 

 

 

 

 

 

 

 

 

 

 

 

Describe In detail how the accident occ\urred (I. 11. Employee was opening a box 1111:! the box c?titter ?llpped laceratn 1113 his loft 11111111111

Cl: MAW \y?it? 1\Ov111 MW ?Wk (0111?. a; 1M 11\ W1 Loy/L5 111101 1310 111
Ho 111/1111 ?111111) 1111 115 1511111101111 1111111111 MM 11111111111111.1111],

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NWWL contact lnErrng of Witnesa: None Was Yes No Were other employees Injured? Yes No
yogi.? 
6111'!? LUZ ?02 Name 81 contact Information of responsible ?11111? Were Campus Mice notified? Yes No
C) 39:)
Did the employee miss any work related to the injury? Yes Ifyes, Date: Time From: To: 

 

 

 

         

MEDICALINTORMATION 

 

 

 

 

.11. . ?142:4 
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Medical Treatment Required Medical Facility If other please complete the followmg: .
Wham Rees~Stealy 1?

0 None 0 Emergency Room - Physician/Facility Nome: 
0 Aid 0 Hospitalization C) Other Address:
Medical Care Ph .

17111111011010611/ 

 

           

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will be taken to 11111111111 recurrence? Check as many as apprOprlate
Safety Guidelines Developed Employee CounSeled Safety Personal Equiament Ordered
Training Scheduled Repairs Ordered Other: . 111151151
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1 AN Allin-?? 
60111111111111 By (Print Name) . giggliature I: 35}; 

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 REPORT OF WORIQRELATED 

Qomplolo lirlo form in llio entirely and oubmlt within all-homo of the lninry
SAN 0mm mam: - Please fax to 61945944013


File as: Date of ir ury Time of Injury
C) Worker?s Compensation Claim I {Vl?q?r?i?f} goo?an
Incident Only Report Supervisor?s Elite 0 (nowlerlge Data Give? to Employee

21?? 

 

 

 

 

 

 

 

 

 

   

 

 

     

      

 

 

 

 

 

 

 

 

 

 

EmployeesNamolLast, First) . . Home Phone LCell Phone Work PDOILQ
. 
Department . Email A 
. I
Sugorylsor?s Name: Supervisor?s Worthone Supervisor?s Email Superviso'lgf;ax

 

 

 

 

 

      
 
 

  

Injurediiorly Part 
Type of Injury



Actlon Causingl

WOW .


 

BACK or raoNror- 
(alrcla Inlurad part1 tulrcla injured pan]

 

 

   

 

Contributing Object/Khulpmont

 

 

left Right Left Right

 

 

 

 

 

 

 

 

 

 

 

 

Describe in detail how the accident occurred ii. a. Employee was opening a box and the box cutter slipped laceratlng his left thumb.)

If .Whoi?m mi? morooracze,

 

 

 

 

 

 

 

 

 

 

Injury occur on campus? Yes No Campus location where injury occurred if not on campus, name address or 5kg
?3 055A Empire/In 4:303 ?4
Name 81 contact information DletnESSi Nana Was another person responsible? Yes No Ware other employees injurad? Yes No
0 0
Name contact information of responsible party? Ware Campus Police notified? Yes No
fr? 0 
Did the employee miss any work related to the Injury? No Yes lfyes, Date: Time From: To:

 

   

   
  

Medical Treatrnent Required if other, planso complete the following: 

None Emergency Room

First Aid 6) Hospitalization
if) Medical Care

Medical Facility

   

Sharp Rees-Steely

 
 

Physician/Facility Name:
Address:

  
  

?35 Other

     
   
 

 

. - . .. .. . . 
Supervisor?s investigallon: What action will be taken to prevent recurrence? Check as many as appropriate.

 

 

 

 

 

 

 

 

 

?Safety Guidelines Developed ?mployee Counseled Safety Personal Protective Equipment Ordered

El Repairsordered Mather: Edmond in ammo: lama,


hammered By (Print Name) Mgn?ture Date 

If?

. . WW ?rs/MA? Rev. 4123114

fig? REPORT OF WORK RELATED 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  
 
 

. umpiete this f'Ol in its-rs if?i?iilit?iy and amount: Wi thin 13tier 
Rbi l'Y

File as: Date of injury Time of Injury

0 Worker's Compensation Claim Jan? 31 2019 1 0.00 am. C) p.m.

Incident Only Report Supervisor?s Date of Knowledge Date Dilig/ 1 Given to Employee

Jan. 31, 2019 26/ 
EMPLOYEE INFORMATION 7

Empioyee's Name (Last. First) Home Phone Cell Phone Work Phone
Department Job Title (Le. Custodian, Student intern) Email 4?
School of Public Affairs 1 
Supervisor?s Name Supervisor's Work Phone Supervisor's Email Supervisor?s Fax
Hours Worked Per Week: Days Worked: Th 5 Start time: a. m. End TimePm- 7200 G) pm.

 

 



BACK or HAND morn or mini) 7 7?
(circle injured part) (circle injured pan}

(injured body Part. I
Other: Head

 

Type of lniury
Other: Pain

ill 

 

Action Causing Inlury

117

Dust/Gas/Fumes/Vapors

 

 

Contributing.Object/Equipment

 

 

 

 

 

Left Right

 

 

 

 

 

 

Describe in detail how the accident occurred (i e. Em pioyee was opening a box and the box cutter slipped lacerating his left thumb 

Headache and vision Issues possibly related to construction fumes in A building Visited nurse practitioner' In after
a few days of headaches.

 

 

 

 

 

 

 

 

      

 

Did injury occur on campus? Yes No Campus location where injury occurred If not an campus, name address of site
6) 0 PS FA
Name contact information of Witness: None Was another person responsible? Yes No Were other employees ln]ured? Yes No
El 0 0
Name 8: contact information of responsible party? Were Campus Police notified? Yes No
Did the employee miss any work related to the injury? No Yes ifyes, Date: Time From: To:
C) (9 2/1/19 8:00 a. m. 4:30 pm.
.V .
Medical Treatment Required Medical Facility if other, piease complete the following:
G) Sharp Rees-Steely
0 None 0 Emergency Room Physician/Facility Name:
0 Md 0 Hospitalization Other AddressPhone:

 

 

 

    

 

 

 

 

 

 

 

3.. - . - - CORRECTIVE ACTION
SUpervlsor's investigation: What action will be taken to prevent recurrence? Check as many as appropriate
Safety Guidelines Developed Employee Counseled Safety Personal Protective Equipment Ordered
Training Scheduled Repairs Ordered Other: SUMAti?ipai?i Succinate 25 MG
1\ 
3/20/19

Completed By (Print Name) Signature Date
urn-z;

QRev. 4/23/14

[If SUPERVISOR 5 REPORT 02: womcnemreo LNESS

Complete this form 222 its entiiety and submit within 244202.223 of the

SAN 522222: ?eas" fax to 619 5944013


2 nj Li ry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  
  
   
  

 

 

 

File as: Date of injury 21? It? Time of Injury - 1 
Worker's Com Jensatitm Claim ww4:13? 3:34; \Igincident Only Report Supervisor' 5 Date of Knowledge Date DWC 1 Givento /mpioyee 
ze 2c?
. 2 EMPLOYEE . . . 
Employee's Name (Last, First) Home Phone . . Cell Phone Work Phone
DepartmentxJ Job I Email 
. 2* 2
KM 22? firiitit 5,2 . ?2 I J2
Sopervisor?s Name Supervisor 5 Work Phone Supervisor's Email 22 Supervisor?s Fax
em. 2 
HoursWorke?d Per Weiak Days Worked: MF Th Starttime: 5.222. End Time: 0 22m.
~20: 2222 [2 2:2 2:2 [32:2 0 pm p.22Injured Bod Part OF HAND FRONT OF HAND
head W739i (circle injured nan)

(circle Injured part)


Type of In] jury Xi?? 2Y1 (J


Mr 010%:
Action Cauding injury I I
Dakotas: Y) "51-
Cit? 
Contributing ObjectJ/Equipment

 

\illi/ 

3 

 

 

 

 

Right Left Right

 

 

 

 

 

 

 

 

 

 

 

Describe In detail ho the accident occurred (i Employee was opening Greet int??! a 2'5 

\Imvvxi?u?f? (A2 (in; ?2%in '30 row

Did injury occur on campus? Yes No Campus location where injury occurred

22 0 oer?22

tter slipped IacIeratlng his left thumb.) ,2
\Wm v?pm-i \hnC- in ii?

 

 

 

If n?oton campus, name address of site

 

 

 

 

 

 

 

 

 

 

 

 

 

Name 82 contact information of Witness: ?03:2 Was another person responsible? Yes Were other employees injured? Yes 3
Name 82 contact Information of responsible party? Were Campus Police notified? Yes No'
I i
0 2?32
Did the employee miss any Work related to the injury? No Yes if yes, Date: Time From292?? [pom

 

      

 

2.25 2
Medicai Treatment Required Medical Facility If other, please complete the 
0 Sharp Rees?tealy . 
0 None 0 Emergency Room Physician/Facility Name: 
OlFirst Aid 0 Hospitalization Other Address:
?RMedicai Care
Phone:

 

 

    

 

    

.. - . -. CORRECTIVE ACTION
Superwsor?s Investigation What action will he taten to prevent recurrence? Check as many as appropriate.

 

 

 

 

 

 

 

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Safety Guidelines Developed Safety Personal Protective Equipment Ordered
Training Scheduled Repairs Ordered ?lOC?'im?? Iv (Chitin/WI bl?!
A .2 I) chI? name
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2 3:2 an
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REPORT wombat-ammo 
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3/1/2019, 12:37 PM

Comp


 



MN Dilutisl 

REPORT OF WORK- RELATED 

lete this form in its entirety and submit within 24 hours of the injury
Please fax to 619-594-4013

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

- 
I I I UL) <5)Ulq 91/192" 
File as: \ytlU Date of Injury Time of Injury
rker?s Con ensation Claim . - - . . . .
?19 '9 lei? paoeliwmw Oam ?Wm
Incident Only Report Supervisor?s Date of Knowledge Date en to Employee
ll 2L9 ll?i 2i eull?i
EMPLOYEE INFORMATION
Employee's Name (Last, First) I Home Phone Cell Phone I Work Phone
I
Department Job Title (Le Custodian, Student Intern) Email
PSFA
. 
Supervisor?s Name I Supervisor?s Work Phone Supervisor's Email Supervisor?s Fax
Hours Worked Per Week: Days Worked: M-r Th 5 Start time: a.m. End Time: 0 am,
8 0 pm. 4.30 0 pm.
INCIDENT INFORMATION
Injured Body Part (circle Inlured part-l-j\ BACK OF HAND FRONT OF HAND

 

Type of leitrw- <9 {bin 8'
nose bleed, headaches.

 

Action Causing Injury

 

Contributing Object/Equipment

 

    



(circle inIured part)

(circle Injured part(II Iz?fi liI' ?.Ii ll 
I 1/ 

Left Right Left Right

 

 

 

 

 

Describe In detail how the accident occurred Employee was opening a box and the box cutter slipped lacerating his left thumb),

Work being done on the roof of PSFA which caused the fumes to enter into the building.



mus. lac

Hamil/I, gill if It Quiet/dis mum

CAM Lcoi? I041

 

 

 

 

 

 

 

 

 

 

 

 

 

Did Injury occur on campus? Yes No Campus location where Injury occurred If not on campus. name address of site
(9 PSFA Building
Name 84 contact information of Witness. None Was another person responsible? Yes No Were other employees injured? Yes No
"In? sin-(1F IIEI 
.4 2L1 HQ Lat/Tl 12' 0 ?i Name 84 contact information of responsible party? Were Campus Police notified? Yes No
vaIILpit m5 0 0
Did the employee miss any work related to the injury? No Yes If ye?, Time From! 1

0 Lil/?7 .0631) j?L?l: 
. . . MEDICAL INFORMATION - I
Medical Treatment Required Medical Facility If other, please complete the following:
0 Sharp Rees-Stealy
None 0 Emergency Room Physician/Facility Name:
0 First Aid 0 Hospitalization Other Address:
cl~ 
0 Me Ica are Phone:
CORRECTIVE 
Supervisor?s Investigation: What action will be taken to prevent recurrence? Check as many as appropriate.
Safety Guidelines Developed El Employee Counseled Safety Personal Protective Equipment Ordered
Training Scheduled Repairs Ordered Other. it! iliHlD? aii?iilf?l?b ID WIT/zit

 

 

 

 

Completed By (Print Name)

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019' cf . 372W

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Date

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Revs 4/23/lxl

 it} or. WORM-RELATED 
Cnmpioto this; form in its; ontlroty and submit Within Muhours of tho injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SAN Pleads: fax to Bis-5944013
Limvrm rv
Filo as: Date of Injury Time of Injury
Worker sCompensatlon Claim ?sh :24? R51 g/ 0 am. jg) pm],
lncidenii?inly Report Supervisor?s Date Rntmiilwc?ii idiitmpinyee
?wm Fol/3 (o flit)! 
. .. -. . . tmrinyrtiuronmnrion - -., . . 
First) I . Home Phone . M, Worlthone 
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Department Job TItleita misludinn,5:uilantIntern] EmailSupervisor?s Name I Supervisor? 5 Work Phone Supervisor's Email Supervisor's Fax
9 il 
HoursWorit?d PerWeek: Days Worked: IMF 5 Th Start time.

 

 

 

 

 

 

 

 

   
  
 
    
  

 

   

 

I. . W. 
injured Body Part 
in U5

so
Typo of Injury
@?gnx?w?y
Action Causing injury
butt C?Ulvk?l (I 0 

Contributing Object/Equipment

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BACK or HAND mm or 

[circle Injured pan] iniureilnorti

My in 



mad" -

 

 

 

 

 

 

 

 

 

Len Leli night

 

 

 

 

 

 

 

 

 

 

 

Describe In d?tnil how the accident occurred {i a it (iployee Was opening a box and the box cutter slipped lacerating{ his left thumb)
'Wm. inns hm? 0i ?34 0 pi or (it clingy) {e 0% died?, 5 . 

it iaecavw Error/w \l (two?p?riemu?cc 5i liMphlamj/ attEoWr-?i??l-

 

 

 

 

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Did ?My occur on campus? Yes Now Campus location where injury occurred if not on campus, name address 
63' r?
?3 0 i ?St" 4
Name 8: cantacl information of Witness: None Was another person responsibia? Yes No Were other amployees injured? Yes No
(I) 0 (3
Name 1% contact Information nl?msponsible party? Were Campus Puiice notified? Yes No
0 

 

 

 

Did the employee miss any work related to the injury? No Yes If yos. Date:

-v 
a

a sii?q 3?52?} 'Q.-.
Monica! Facility if other, plensa complete the loilow?mg:

C) Sharp Rnas-Sienly

 

Time From: To:

   
  
    

 

 

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tax/?31: 3.:

Mane 0 Emergency Room Physician/Facility Name:
0 First Aid 0 Hosrnitaiization Other Address:
0 Medical Care

Phone:

 

 

 

   
     



hat antiOn will be taken to prevent recurrence? Chock as many as appropriate.

 

El 53?9?! Guidelines Dovelopad Ll Employao Safe?! Personal Protective Equipment Ordered

Training Scheduled [3 Repairs Ordered ?ame? 5,ve MOW I
vanadium rm if

A . . . 
Completed By (Print Name) . (Br/g: .- 41.. I m?i?




 

 

 

 

 

 

 

wr'? 

 REPORT OF 
Complete this farm in its entirety and submit within Zti~nours of the 

 

 

 

 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

        
 
 
 

 

 

 

  
    

            
        

 

    

 

 

 

 

 

 

 

 

Injury

File :15: Date of Injury . Time of injury
0 Worker?s Compensation Claim km 550 \l (til/3 ??g?ck 1-2133?) 0 mm. C) p.m.
Report Ijl?pewism'suate gmW131 ..
anlnm?n?c Mum): {11ml- Firnl-i HOME Phone mum? 1 Work Phone
Department I Job Title lim?uslodian? swdem lnlornl Email I
knit; M2503 
Sunemisw' 5 Name Supanrlsur's Work Phone Supervisor?s Email .. 5 Supervliiar's Fm:
1
hours Woritgd PerWerak: Th Start time: a m. End Time: . 0 am.
?10 pm.
?Is: 1., {51% 5:121:75: 3w r11; my; I. -. .0. A, 
Iii-i. I 31.45353 3 1g zij?g?i g? 3% RM - 2 3:2' If. Hi
injured Body Part7 BACK OF HAND FRONT OF ?my w"
(drain Injured Imii [circle lniurqu nan)
Tyimofinlsug 
?new {n
Maid man/NM 
Actinn Calming injury
was
Contributing Object/Equipment
@ywt: A I Left night I 1 tuft amt?l

 

 

 

 

 

 

 

 

Dascnbe in detail the accident occurred a. Was box and the box cutter slipped laceratlng his lair thumb) 
(um: i minim i0 ?304? mg??xm Wm cow gm WW: at mint-?I 


ifnot on campus, name address of site

 

Did iniun/ occur on campus? Yes Campus location where injury occurred

No
In: 0 P969
blame 84 contact infor?mation ul?Witness: None anutimr person responsible? Yes No Were other employees injured? Yes No

00 m0

Name contact informatiOn of party? Were Campus Police notified? Yes No

WWL 0 it):

Did the employee miss any work related to the injury? No Ves lfyas, Data:

0

 

 

 

 

 

 

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52:1:
312232332 . 
Winn ?532?, ?is; ?33:

  

if utiier. please complete the foiinwing:

0 Sharp iiees-Steaiv
Nona C) Emergency Room Physician/Facility Mama:
0 Hospitalization 0 Other 
0 Medical Care Phone:

 

. 3?32an 

it. 

      
  

 
  

it; 3% min: . -
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0..
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{33* 2 33%:

[3 Employee Counselecl Safety Personal Protective Equipmanmrdered

[3 Repairs Ortimd gunman al??mw?h??

Training Scheduled

 

 

 

 

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a Completed Wii?rintiiamal Signature Date

6/7/[3 

 

lil




Please fax to 619 594-4013
mm (Ml 

REPORT OF WORIMIELATIID 
Complete thla form in ita and submit wlthin 2441mm of the injury

 

 

 

 

Elle as:
C) Warkar?s 

Only Import

Dam of Injury





Time or 

 

 

 

 



Date Of Knowledge

 

 

 

 

  
   
   


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anlom?s Name ansI. ?rst)

   

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Describe In Ilut?gll hov?ho occur rod [Le Employosz Was upunlng box and the box cultur slipped laceratlng lIls left thumb)
3W v13 umlmj I

 

 

 

 

lnlury? occur on campus? Yes



N0

Campus lacutlon whom Injuw occurred

0 P13 WI

ll not on campus. name 8. addmsa of slte

 

Name a contact Information of 





Yes No

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Were otheremplovees injured? Yes No

CDC)

 

 

?llama 3. contact lnlormatlon of party?

 

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00

 

   

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414.6

    

  
 

 

   

?la?lh 17,1: 3 Y'tl??znt ?g?lraq
0 Emergency Room
First Aid 0 l-losmtallzatlan

0 Medlcal Care

 

if,? I. 
gt] Safety Davalnpad

Tralnlna Scheduled

 

employee miss any work mlnted to the Injury? Nu



 
  

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Ves lfyas?lam: 

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is. 

Phone:

$?Wq?f

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Acldrarss:


43% 653%. .. ?3 . 

.W?lgtlon be taken to pmvent recurrence? Check as many as appropriate.

Employee Counsulnu Safety

?npalrs ardered

 

sa-

[3 Parsunnl Pmtectlvo Equipmant Ordered

Elmer: Wk WW

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Computed By (Print Name}



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35/!4/16



 

1? REPORT or WORK RELATED 

Gompleie: this form In it?? entirety and sluiomi?l within 24?ul"10tll55 of the injury
MN S1 M, Ploaae fax to 6194394 4013
l?Y .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

       

 

 

   

 

Flle as: [mt-e of Injury Time of ln]ury
Worker's Com ensatlurl Claim 8. 1.
0 Sling; Dacmb 0 0 pm.
Report SirpeWisor'SD?ta of Knowledge Wig (r (?1115! ?twirl twee
pl
EMPLOYEE INFORMATION
Emplovee?s elm} Home Phone Cellphone 
Department. I lob Ernall
HTM
Supervism's Name 7 Supervisor's Work Phone Supervisor?s Email Supervisor?s Fax
HoursWorkerl PerWeek: DaysWerkeci: Mi 5 Th . a..m End Time: 0 8m.
48 . 8:80 um? 5:00 (9 limm?lb?NleF 
Injured Body Part ?iciwia'nl'm'ivmll BACK 0f HAND FRONT OF HAND
- . (circle injured pmil
Other: Head
Type oflniury

Headaches and light header


\l 1/

Left Right



 

Action causing lnlurv

Fumes In building

 

Contributing Object/Equipment

Roof Work off 988an

 

 

 

 

 

 

 

 

 

 

 

Describe in detail how the accident occurred (Le. Employee was opening a box and the box cutter slipped lnceratlng his left thumb.)

There [[88 been ongoing roof work being clone which makes an: office email orgasoilne fumes The fumes sometimes become so strong
that I begin to feel light headed and avenlually gel 8 painful headache.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did injury occur on campus? Yes No Campus location where occurred If not on campus, name El address of site
(9 PSFA .7
Name at contact information of Witness: None Was another person responsible? Yes No Were other empluyees injuredName El contact lniormatlnn efresponsiliie party? Were Campus Police notified? Yes No
CWWM QInm 
Did the employee miss any Work related to the Injury? No Yes If yes, Date: Time From: To:
been i?oiwecol [Win 0 2kg 
- fl: 
Treatment Required Medical Facility If other, pl8858 complete the following:
C) Sharp iiees?ilealv
None 0 Emergency Room Physician/Facility Name:
0 First Aid 0 Hospitalization Other Address:
ic
C) Medina are Phone:
[11511111138818 investigation, Wllza?gptlon will Ire [aken to prevent recurr8nce? Check as many as appropriate.
Safety Guidelines Developed Employee CounSeied Safety Pergonal Protective Equipmant Ordered
Training Scheduled Repairs'Orclerecl mmg?mnm 

 

 

 



I 
8, .1 212.88..
88.8111" Date

A . Rev. 4/231! *1

5/l?7/l?9

  

 

 

.?rNNDiliiliHMii
WWI rum

REPORT OF WORK-RELATED INJU ILLNESS

Complete this form in ito entirety and oubmit within 24uhour8 of tho

Please fax to Gill-6944013

 

 

injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

    

 

 

 

 

 

 

 

   

 

  

 

 

 

 

 

 

Filo as: Date of Injury Time of Injury
0 Worker?s Compensation Claim Jan. 2019 Present Ongoing am 0 run
incident Only Report Supervisor's Date of Knowledge Dale DWCulhlven to Employee
1/17/2019 2/26/2019
.. . EMPLOYEE ruronmririou
Employee?s Name {Logo First) Home Phone Cell Phone Work Phone

Department Job Title (La. curmdlamsmdant lntorui Email
PSFA . .
Supervisor's Name Supervisor?s Work Phone Supervisor's Email sunewisor's Fax

Horns Worked PerWeek: Days Worked: M-F Th Start time' 6) am. End Time:
40+ I 880 OW 5:00
- if?) 1. .13" .zui-r; ilfs?oigmrives?lzz i 
Injured Body Part timed mi BACK or HAND mom or HAND
lulrclolnlumd part) lcirciolnjur rt)
Multiple Body Paris a 91
Type oflnjury p? ?q
Oihor: I
Action Causing inlury 
DusUGas/FumosNapors w? - - m"
Contributing Object/Equipment
Ongoing construction Le? Right

 

 

 

 

 

 

 

Describe in detail how the accident occurred (1. e. Employee Was opening a box and the box cutter slipped iacorating his loft thumb.)

inhalation of fumes, vapors, dust other air particles whiio oxisting in the building causing severe headaches and respiratory issues with

 

 

 

 

 

 

dif?culty breathing
Did inlury occur on campus? Yes No Campus location where injury occurred if not on campus, name address of 55m
63 C) PSFA building NIA

Name contact information ofWImess: None Was anothorperson responsible? Yes No Were other employees injured? Yes No
Other PSFA building 111 . 0 0

Name contact Information of responsible party? Were Campus Police notified? Yes No
occupants

0 

 

Did the employee miss any work related to the lnju ry? No

 




 

 

??12
8-

  

red

Medical Facility

 

fig; con?rm or 723!

Yen lfyos. Dare:

0 Sharp Rees-Stanly

Time From:

@None 0 Emergency Room
0 First Aid 0 Hospitalization 0 Other Address:
0 Medical Care

Phone:

To:

Physician/Facility Name:

 

 
 

 

 

Safety Guidelines Developed
Training Scheduled

 

El Employee Counseiocl Safety
Repairs Ordered

in mi 8 
.8 
imigstigptiqu 5W Jam action will be taken to prevent recurrence? check as many as appropriate.

 
  
 

 

Personal Protective Equipment Ordered

@Other: 1/10ny

. . . . MW .l I I. 71?? .ro. 
If other, please complete the following:

?lm/.8101 

  
  
  
  
    
   
  
  
 

   

 

21277201 9

 

 

V. Completed By (Print Name)

A

Signmh Inn

Date

85/1?? 

 

 

I OI WORK 
Il'IsIl 101111 1151 @111?st and 111.1b11111wi1h1n 01111.21 injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

      

      

SAN Dugd?mn P1963519 fi-JX I20 61943944013

Flle as: Date of Injury Time of Injury 
0 Workers campensaLlorIClalm 01 I I ?1 .p (3 am, 0pm.
IncIIlentOnly Report SUpervlsor's Data of Knowledge Date CIWC-J. leentu Employee
1 
(J II 
- IMPI om: INFORMATION -, 
Employee's Name (Last, ?rst) Home Phone Cell Phone Work Phune 
Departr??'nt I Jab Email A -
1 l' A
V5111 . . - .
Supervisor's Name SLIparI/Isor's Work Phone Supervisor's Emall Supervisor?s Fax
Hours Worked DaysWorked: M- 5' Th am. End Time: . 0 a 
11-0 .. . 13? In [31:1 1111:: 0 pm Ange (ED pm.

          
 
 

 

   

 

 

 

.1311 I-aw .
Injured Body Part BACK OF HAND FRONT OF HAND
IcIrcIa Injured narll Injured mm]
Type of Injury

 

?13le and. 

 

gnqauaiy 322
I?ll 

Object/Equipment

 

WV

left Left Right

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

umbrella 66.131! 116W Rammed {i 1: Employee was opening a box and the bax cutter slipped lacerating his left thumb .

I1 3/11an - IMF comm/u cm WI 12mm raw/w! 3M6 My 
I 111M mum many Mama?! by] 0&1?me

1:115?;

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

?61171qu uncurcm ?ampus? Yes No whnmihmw If not an campus name Is. address of 5m
?3 13511116111131.?
Name 94 cuntuct Information of Witness: None Was anuther person ?M's Nq Were other employees InjumdName II: contactinfarmatlon of party? Ware Campus I?olice notlfled? Yes No
0
Old the employee miss any Work related to the injury? No Yes ?yes, Date: Time From: To:
C) 

 

 

  

 

 

MEDICALF .1 .. 110.11

 

 

 

. . . . . ?'Ijl
?lag Meclicai If other, please complete the following:
0 Sharp Rees-Stealv
0 Emergency Room Name:
0 I?IrstAld Hospitallzation 0 Other Address:
I ICar
0 Mad as Phnne:

 

 

 

 

 

 

 

 

 

 

 

gagew Guidallnes Deueluped Emplayee Counseled Safety If] Personal Protectlve Equlpment Ordered

Training Scheduled Repalrs Ordered gum?" 
- 11>th %l 

 

 

 

 

  

111111 

WCompleted By Name) Signagm/ 7 Date

g/Iq/I? Rev. ?ll'Z'lIlIl

Elm 5U REPORT OF 

.1 . Gomnlete this form in lie entirely and submit within minimum 555? the inlury
SAN [3mm Sm? Please fax to 61943944013 
UN ill-ll FY
File as:

 

 

Data of In] I . Time of injuryi
C) Worker's Compensation Claim (21/ QLZ 4/ 6 am. My) 
?lmident Only lieporl Supervisors Wild [51? legal? 

. 

Employeelshiamn ll acl- armHump Dlumu .5 .. 1., . 1"}ka Pm 

 

 

  

 

 

 

 

5E

\Qmwauvn? 

 

.5 

 

 

b. w-v v. lur

Deparr?): .ianitieI- . A [amenName I I SUHQNISOPS Phone [Email I Slipervlsur's Fax
Hours Week: ?Jays Worked: M-F 5 [Effie Starl Us?! (gram. EHW

38"? -r ?in -- 9-5555." .. . Qupu . .. .. 
'rsv': ht" rENn?N?m?MAroN-m ?it "Rig. . .. . 
may) 3 Injured 115ml {?1,le Mum, Mr"
K.

n,

Willi! 

Actl Gaming Injury

rue 5'9

Contributing Object/Equipment

 

 

 

Iii/I?

Left High! 175% Right

Describe In detail how the accident occurred (l 9. Earnings:{ was opening 3 51cm and the box cutter slipped lacerating his left

Mair/Ir being lulu/elegy? pmm?l WW 21

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

    

 

 

 

 

 

 

 

 

Did injury occur-on campus? Yes No Camp location where Injury nr rred Ifnnt on campus name lemmas-s si AMFG
.55 uni
Name 8! contact information of Witness: Nana Was another person responsible? Yes No Warn other employees injured? Yes No
[ll 0 C) 
Nama Ki contact of party? Were Campus PolleW?fmh?WW?W?
the employee miss any Work minted lo the injury? No 0 lg

Yes gnaw? o. 



 

 

  

 
   

 
 
  

Inrohmnnon .

 

 

 

 

 

 

        
   

l" I 
--I 2" 
Medic'ai Treatment 'Required Medical Facility ll ot'her, please complete the following:
(it) Sharp Reeseiealy
None C) Emergency Room Physician/Facility Name:
0 First Aid 0 Hospitalization 0 Other Address:
0 Medical Care
Phone:
. 55%" -. .
laggiw 4'13: 5 WI ACTION ii? . ?v 5 

   

ligatih??a Wi?i'a5" ?i'rilon will be taken to pre'vrent recurrence? Check us many as appropriate. MW 

 

 

 

 

 

 

 

 

Safety Guidelines Develolaed Employee Counsnied Safely Personal Protective Equipmanmnjemd
Training Scheduled Repairs Ordered Wilmer: m1? mm
. . [mama 59V) 5 I'll??
Elem
?gilnp'lutr'acl l3y [Print Name) mug} . Data
. . .M 5 

Aql?lqnnu IU'l'Ifl,?

 

SUPERVISORS REPORT OF 

Complete this form in its; ontiroizy and oubmit lad-homo of Iho' In

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

      

 

 

 

 

. 
SAN Drum r. i??lonse Inn to 619 89441013 I 

Filo as: Dale of injury Time of lnIury .
(j Worker's Compensation Claim .2 (I) L0 0 run a? 
Incident only Report Swen/15W 5 Dr: oIKnnwiarige OWE
f. . .
- [pl 20:: 7mm; 
. . IINI PLOYEIE . .. . . .
Employee?s Name (Last. Firsti Home Phone Cell Phone Work Phnno
. . 
. A?Vf1b I
Department I Job TitIeIm. Custodian,studonumami . I [Email I 
o? :1 ?In. .1 A- .4
(5 I '{Ngr I .W. .. .
. uporv set 5 me Suparv sor a Work Phone Sopewiror 5 Email a supervisor:s Fax . A 1
Hours Wdrkeri Per Week: Start tlmo: C) a.m. End Time: LPG a 
A 

 

 

 

Injured {50:1pr 
I'm-aft.
I (a U??b'faw'"

 

Type of Inlury

 

 

 

  

    

 

BACK or HXXID I i 

(clrciu Inllired part}

 

   

{15.31. - guru?
FRDNI OFIIAND
Icir<in1ninrnri part)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i NECK L4 6'0 l" 
lint innit-?Ii 
AcIIon Causing Injury
one; 
Contributing owed/Equipment
[33? '51th Left Right Left: Right
- M)
Describe In detail how the accident occurred Ii. 8. Employee was opening a box and the box cutter siippad lacerating his left thumb.)
. . .- -
Lfrf?I?S I any MIN #4 Mirth/g
g) pig? L4 2, any
Did injury occur on campus? Yes Campus Incitinn where lnlury occurred I If not on campus, name address of site
at)? N00 mmeWI-whnm
Name i3: contact Information of Witness: None Was another person responsible? Yes .. No Were other employees Injured 3? Yes Nu

(rm-riName 8r contact information of responsible party? Wore Campus Police notified? Yes No

. C) Cr?
Did the {employee miss any Work related to the Injury? No Yes If yes. Date: Time From: To:

 

 

 

 

 
 



  

 

 

 

 

@Iione 0 Emergency Room
0 Md 0 Hospitalization

0 Medical Care

Medina! Fncility

0 Sharp Reesismaiy

Other

Address:
Phone:

 

 

"other, please complete the foliowing:

Physician/Facility Name:

 

 

Safety Guidelines Developed

Training Scheduled

 

Employee Counseied Safety

Rnpaira Ordered

Personal Protective Equipment Ordered

 

 

 

 

 

 

 

 

 

 

 

113W 3! 
Sol/(in 
1CompIQth ByIPrinlNamaI Signature I I w- .m 



 

 

 

 

 

   
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

      

 

 

ii? i? REPORT OF ILLNESS
Complete: thin form in its entirety and submit within Sizinhonro of tho injury
SAN DilimSwI- Please fax to 619694-4013
ilNWiItHIn?
File as. Date aim (in; Time of Injury
Worker's Com ensatlonClaim IncldentOniy Report Mf?gispranteoilinowiodge ?pin gnoloyEmployee?s Name (Last, First) Home Phone Cell Phone Work Phone
.. . .- 
Department" Job Ema? 
a" I -- 
. 
Supervisor?s Name SUpervisor's Work Phone Supervisor's Email Supervisor?s Fax
Hour; Workocll?erWeolc: Days Worked: Th ?7 Start'tima: mm. End Time:

     

        
  
 

 

 

 

(313 

 

   

 

 

 

[?f?ed Bodxi pgn' (in, . manor HAND FRONT or hind? 
agas? MW Icimia InIu rod pnriI? {clmie [mumd pa rt)
wa?
Type of injury 
\oOii? r1 WW3 
some?, Nahum WW
Action Causing iniurv

wows: Mum 

 

 

Contributing Obieutf?qulpmont

 

 

 

 

Left Right Left Right

 

 

 

 

 

 

 

Describe In detail how the accident occurred ite. Employee was opening a box and the box cutter slipped iaceratlng his left thumb.)

'9.?th 67" Mai kiwi) clam. (W ?M?WJ?ic/im

 

 

 

 

 

 

Did injury occur on campus? Yes No Campus location where lniury occurred If not on campus, name address of site
Namo contact information of Witness: None War. another person responsible? Yes No Were other employees Injured? Yes No
Nomi: 8! contact information of responsible party? Were Campus Police notified? Yes No
ti) @5
Did the employer: miss any work related to the injury? No Yes If yes, Date: Time From: To:

 

(D 

 
   

 

    

 

. mini-main . . i
Medical Treatment Required Medical Facility if other, please complain the following:
0 Sharp Rees~3tealv
None 0 Emergency Room Physician/Facility Name:
0 FirstAid 0 Hospitalization Other Address:
0 Medical Care

Phone:

 

 

 

.
f" 
- u, . 

   

 

Safety Guidelines Deveioped Employee Counselor] Safety

Personal Protective Equipment Ordered
[3 Training Scheduled

RenairsOrdered El?therzw?dd ..
9110mm t?m? 

 

 

 

 

  

 

A . . WW "Jig-l wasghd a:
?com ietedBviPriniName) 

Signature: Date

x?o?o"

.. REPORT WORK REI ATED 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

      

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   
    
 
 
  
   
 
 

 
  
 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

 

 

Complete this IOI In in its; aniim?ay and nuhmii: within Mu-hmn?? Of the iniury
SAN Plaase fax to 61 9-594. 4013

File as: Date of inlurv Time. of iIIlury 
Worknr's Compensation Claim 0le0 (ciclant OHIY it apart Supervisor?s Date of Knowiedge 
47"? .231EinnIWeIe 5 "Name I-?lrstI Home Phone . Phone
DepaIImeVnt WV I 16b Titian?. I Email 
. . - DU
Supervisor's Name Sllpervlsor's Work Phone Supervisor's Email I Sllpervlsor 5 Fax
Hours Worked PerWaak: Days Worked: MP 5 Th 5 Start time' Iggy-am. ?(Enid ?me am.
I3 I: 4-. 
. 1"l?1. ?Raj-5 
3.3% . 1% I .55. ?isn?m
Injured 86th; Part BACK OF HANEI I FRONT HAND
{chain purl) {circlu InjmaII pad)
Typeoflnjury 
Action Causinginjurv . f,
. km.? 
GAS FI) ME E:
Contributing Object/Equipment
. I ht
mm 

 

 

 

 

 

 

 

 

 

Dascribe in data" how the accident occurred (Le. Employee was opening a box and the box cutter slipped Iaceraling his left thumb}

Fun/i628 C?ufmib 4% MAUIQEA

 

 

 

 

 

 

 

 

 

 

 

 

 

Did Injury ocdur on campus? Yes No Campus location where Injury occurred If not on campus, nama address oi site
RIVA 
Name 8: contact information of Witness: Nona Was another person resinonsible? Yes No Were mher employees Injured? Yes No
Name EI contact information ofmsponsibie party? Were Campus Pniita notified? Yes No
?i
Con (amwnorxl 0 x5
Did the employee- miss any work (elated to the Inlury? No Yes if yes, Date: Tima From: To:
(3 

 

{I?d
1- I

:?M?i?yz If": '3
MIL, Ii

Ins; 

 
      
 
 
   
  
 
  

 

 



C) Sharp Rees-Stanly



 

MedlEaITraatnIentIiethIred I .. 

Mane 0 Emergency Room
0 Flrs't Md 0 Hospitalization 0 Other
0 Medical Care

Physician/Facliiw Name:
Ad dress:

Phone:

 

 

       

122:: -- . 
. . . 3128!: II I. .
If ?Ii action beI taken to prevent recurrence? Check as many as apprOprIate.

    
  
  

 

Safety Guidelines Devanpeci Employee Counseiad Safety Personal Protective Equipment Ordered

Training Scheduled RapairsOrclaI?ed aim

i ?l?l?i

1? Sigrlfiture Data

?lm: Dim 

 

 

 

 

 

 

 

 REPORT OF WORIORELATEQ 

 

 

 

 

 

 

 

 

 

2 2 Gomrzloto ti'rio iorm in its entirety and ssuiarnii iihiri 2442mm oftho injury
SAN Dims} S'rnr?l- Please fax to 619-594?210?
UMlVi'llh?l'iY
File :25: Dale of Injury Time oF injury 
Qt) Worker's Compensatmn Claim 0,160 07/? am C) om. 0pm.
2693212;de Only Report [Willi l?gt?gg?l?t-Qlla??PWHill1"JFirst) . Horne Phone Ceii Phone I Work Plione I
Department lob Email 1 ?4

Supervisor?s Name Supervisor's Work Phone Supervisor?s; Email Supervisor's Fox
:v
HoursWorked PerWeek: DavsWoricesi; 3 Start tinm?ima?) nan. End Time: than? yr 
2/0. 
or wire 222222 22 2222* .2 5" 2222.22.22,? 
. 22.? 3232? 222222122 3i .2 {53.1233 71 ..
Injuredw Body Port FRONT OF HALO
lutrclo inlurod purl}
Type oflnjun; \Hn/ ?Hf
. 1
Action Causing Injury 
Elli/No We? .2:
Contributing Obiect/Equlpmerlt
vjt?otll (ll-f quc?t Left Right Earl Right

 

 

 

 

 

 

 

 

 

 

 

Describe in detail how the accident occurred e. Employee Was opening a box and the box cutter slipped Iaceroilng his left thumb lac-2:. been; lxa v1 .4 IPA

WNW wet/a ?lo/l1 he

 

 

 

 

 

 

 

 

 

 

Did Injury Deal.? on campus? Yes C?Bmp?s location where injury occurred If not on campus, name 8. address of site
(?97 0 l) 33/
Name 82 contact information of Witness: None Wan: another person responsible? Yes No Wore other employees injured(I)
Name 82 contact information of responsible party? Wore Campus Police notified? Yes No
Did the employee miss any work related to the injury? No Yes If yes, Date: Time FromMedical Facilitv
.. C) Sharp Rees-Steely
gm? 0 Emerge? Physician/Facility Name:
First Md 0 Hospitalization C) Other . Address:
0 Medical Cara

Phone:

 

 

 

    
        

  
  


ts

mint. -- at
nz?Wl?Pt actlon will be taken to prevent recurrence? Checlr as rnanv as 

Safety Guidelines Derelopod Employee Counseied Safety Personal Protective Equipment Ordered

Renalrs?l'demd ?othon RQIWW 3'41?

  

 

 

 

 

.r 
2.42.?

 

 

 

 

 

 

 

2/27/41
Completed Slgliahlm 
?lt?bd?) lug!

 REPORT OF WORIGRELATED 

complete title norm in ite entirety into outnnit within Ednhoure oi" tho injury

litres-:1 in Hi Please fax to 619?594-4013
lNix i lot it

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

File 215' - Date of Injury Time of injury
. Worker?s Compensation Claim 2&8? afternoon 0 am. pan.
incident Only Report Supervisor's Date oiKnowledge Date Given to Employee
3/8/19 8/811 9
EMPLOYEE INFORMATION . . .. -
Empiovee?r Name (Last. First) Home Phone mI Phone Work phone
Department Job Title lino. Custodian, Student lntornl Email
JMS .
Supervisor?s Name Supervisor's Work Phone Supervisor's Email Supervism?s Fax
ix . 
Hours Workedli?erWeuk: Days Worked: NH: 5 Th am. End Timer mm.
40 (16 on oompu: [g 840 0 36:40 p.Inlurorl Body Part BACK Oi? HAND FRONT OF HAND
-. (circle injured nail] (circle injured part)
r, . . .
i?ypeoflnlury Headache Action Causing injury 7 
NIA . i -- 1?
Contributing object/Equipment
fumes in PSFA Left Right Lien Right

 

 

 

 

 

 

 

 

 

 

 

Describe in detail how the accident occurred ll. e. Employee was openlnge box and the box cutter slipped his left thumb.)

On 2/28/19. error reeling eon or light?needed while working in my office (memento). I begun experiencing a mlidwio~eevere mlgranewllko
headache. i have continued to experience this chronic headache on and off for 12 days. I've slnCe been working remotely due to the fumes.

 

 

 

 

 

 

 

 

 

         

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

Dirt Injury occur on campus? Yes No Campus location where injury occurred if not on campus, name 81 address of site
0 PSFA
Name it contact Information of Witness: None Was another person responsible? Yes No Wore other employees lnlured? Yes No
0 0 6)
Name 3: contact Information of responsible party? are Campus Policie- notified? Yes No
Ci
Did the employee miss any Work related to the injury? No Yes if yesJ Date: Time Front: To:

. psi.? ?hedroeiriirinoij, 5? . mm
Medical reatment Required Medical Facility if other, plans
0 Sharp ReeSvSteriiy 
C) None C) Emergency Room Physician/Facility Nome: . A
C) {3 Hospitalization Other Address: - --
(3) Medical Care
Phone:
(It
.V . - :213.. 5.1. I 
5.14321 -. x. .. . .. CGRRECTIVE . - I. . - 
action will be taken to prevent recurrence? Check as many as appropriate.
Safety Guidelines Developed Employee Counseieri Safety Personal Protective Equipment Ordered
Training Scheduled Repairs Ordered gum. 
yer 
WW

2 .
Completed By (Print Name) Signature Date

A

A Rev. M23114
w, M, 3/16: 19?

 

 

SAN lilliinh! 
ll?Il 5'

REPORT OF WORIGRELATED INJURYIILLNESS

Complete this form In its: entirety and ouhmit within 24410qu of tho injury

Please fax to 6153-5944013

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

  

 

 

 

 

 

 

 

 

Action Causing Injury

Dust/Gae/FumesNapora

 

object/Equipment

 

 

 

Filo as: Date of iniury Time of injury
C) Worker?s Compensation Claim Fohrunru 2019 lonooinoi C) am. pm.
G.) incident Only Report Suparvisor?a Date of Knowledge Date ch~1 Given to Employee
19 3t7u1g
. I 5 .. EMPLOYEE INFORMATION I. . . . . .
Employee's Name (Last, First) home Phone Cell Phone Work Phone
NIA 
Department Job Email A 7 7
Public Alialrs 
Supervisor's Name Supervisor?s Work Phone Supervisors Email Supervisor?s Fax
HoursWorlted Per Week: 5 Days Worked: ?il 5 Start time' 0 a m. End Tim: C) mm.
24 (in Office/classi I. [If33.; f? 7'5" i 
. hiNronhihrion . .. I. i, 
iniured Body Part BACK or HAND mm or HAND 
(cirole Injuruo part) (circle injured pa 
Other:
Type of Injury
Other:

 

?l 


.. 

 

 

Left Night left . Right

 

 

 

 

 

 

 

 

Desnriho In detail how the accldant occurred (Le. Employee was opening a box and the box cutter slipped lacerutlng his left thumb I

There are fumes In our building from construction conducted over the past law oi weeks. i have had Irritation breathing lsouas and
headaches since then. Note we have received asbestos notices: many it

mos over the years as wall.

 

 

 

 

Rid-Mimi mono? Yes No Campus location where Injury occurred I if when campus, name 8: aderSS oi site
PSFA 
Name gt contact Information of Witness: None Was another person responsible? Yes No Worn other employees ln]ured? Yes Na
- (a 
I Name 8'4. contact information of responsible party? Were Campus Police notified? Yas No
Construction oomoanv (unknownl 

 

 

 

 

 

Did the employee miss any Work related to the Injury? No Yes If yes, Date:

 

Time From: To:

 

 

 

 

I Merlical Treatment Itequlred

None Emergency Room
0 First Am 0 Hospitalization
0 Medical Caro

 

 

Safety Guidelines Developed
Training Scheduled

 

 

    

 

Medical Facility

0 Sharp Rees~$teaiy

?3 Other

 

1 hag-f5, - a. I. .


 

 

 

 

 

If other, please complete the following:

Physician/Faculty Name:
Address:
Phone:

 

 

 

 

 

Employee Counseiocl Safety
Repairs Ordered

 

Personal Protective Equipment Ordered

[Heathen 32?:le +0 WW [Qua]



 

 

 

Completed By [Print Name)

3-1 1 ?01 9
Date

Rev. 4123114

 

 

summi/Ison?s REPORT 0F WORK RELATED LNESS
{.?mnpietn this; form in its matisweiy and autumn within Muhwrn oi the:

 

 

 

 

 

 

 

     
 

 

 

    

 

 

 

 

 

 

 

 

 

 

 

    

 

      
 
   

 

 

 

 

    

     
   
 

  

 

 

 

 

 

- injury
SAN Du (i0 Sm r1- Please fax to 61969440 I 3
UNIVI llHi'l?Y
File 115: Dale nilnlury Time of injury 
Worker?s Com ensnlionCiaim . .
C) [m gran/Lt; I1 PW w! ?52411. 0 a pm.
IncitlantOnly Report ?Silvetilil?ynwaieofkna 39518351: Wltil?ilm??q jyegx. quElnploy?e
.14 2m in
:iEmployee? 5 mm: Home Phone Cell Phone Work Phone
-r gwccDepartment '1 Job Title p.11cusimii1n,SImleniImam] all
yam .. 
Supervisor?s Name Supen/rlsar' 5 Work an119 I Supervisor?s Email Supervisor?s Fax 
Hours Worked Pnrw?l?il: DaysWorMce-d EmiTime; 
p.111.
I I'm'YI-?gt 53.5 v.ngtiilii?iniilizt;
B?dv Part I BACK OF HAND FRONT OF 
a: ltirtlo. Injured pnril {circle injurud pan]
Ma?p?xnm Mitt/HM Min 4' .
Typecilnjury 
ML- 5:1.11. gm .34 64% 
Action Causing in .4- 


balmy; . 14194243849; WM
Contributing Obja'ct/Enulpmentu 

 

 

Left Right I Left Rial?

Describe in detail how tile accident occurred ii. 13. Employee was opening a box and the box cutter slipped laceraling his left thumbme? 4144449444? M449 43.2.1. cry/awn
'M?f fiwllui?itrbw? MAL an mine?

Did ini?ry occur on campus? Yes No CampUS location where iniury occurred

. 9 643%.
Name 8: contactinformatlon of Witness: None Was another person ?I?es ,iiln Were othat employees injured?

Ys
.. 1:1 0 

No
b14751? zip . 0
Name 81 contact information of responsible party? No

 

 

 

 

 

 

 

 

 

 

ii noton campus. name 81 address at site

 

 

 

Wen: Campus Pq dial noilfie'r]?

 

 

 

 

    
 
  

    
  

 

 
 
 

      

 

 
     
  

 

 

 
 
   
  
 
 
  

 

 
    
   

      

Yes
Did the employee miss any related to the injury? No Yes ifyes. Date: Time From: To:
:4 .- j, [336 3m 111qu i {1555:3711?3; ,1 Md??fgfg?mg? Mfg, I.
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0 Sharp Rees~5tealy

None 0 Emergency Room 0 Physician] Facility Name:
0 First AM 0 l-luspltallzation Other Addresg: 
0 Medical Care

Phone:

 

 

 

    

  
 

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lfl?gi?si I I.

 

 

 

 

 

him? (aim-t? margin lat-1W 4 
Vhatactlon will be taken in prayeni recuirenre?? Chen elsrn nyas appropriate.
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Safaty Guidelines Developed Employee Counseiaci Safety

Personal Protectiva Equipment Ordered

Repairstirclered We?ll? S?ewi- MMhif?u 'h
Emma (m Magma;

Training Schaduleil

 

 

 

 

 

Completed ByiPrintNama)

Slgn? Date

mm

UNIVI 1w i 

Please fax to 6196944013

14 - SUPERVISO ii?S REPORT or 
(Samplers: this mm in its; entirety and submit within 2441mm hi the ir

ijury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

   
 

 

 

Fill: as: Date ofiniury Tima of Injury
0 Worker's Compensation Claim Jan/Feb 2019 0 mm. 0 pm.
6) Report SUpervisor's Date oilinowiedge i @W?il' qlErppl yer.
Jaanob 2019 My 1%
. . LMPLOYEE iNr=6rrMAn6N . - . 
Name llasr. rim) Home Phone Cell Phone Work Phone
Department Job Title ll.u. curiodlnn?ludum Imam} Email Nm?_
HTM 
Supervisor's Name Supervisor?s Work Phone I Supervisor's Email Supervisor's Fax
Hours Worked For Week: Days Worlcod: 5 Th Starltimo: am. End Time 0 run.
I mm m] [3mm 8:00 Qim- 2:06 (9pm
I '11. 1 finInjured Body Part

eyes, throat, head

 

Type of injury
lrrlaiion, headaches

 

Action Causing Injury

Ghonricals in the air

 

Contributing Object/Equipment

 

 
 

[circle Inlmmi part]

  

nA'riK 

 


OF HAND
lcircia Injurmi part}

\i'iil/
i 

 

 

 

 

 

Leil

 

 

Flight

 

 

 

 

[inscribe in detail how the accident occurred (1 8. Employee Was opening a box and the box nutter slipped laceratlng his left thumb 

The PSFA building has been underconairuciinn for many months. For the ionl month there has been toxic smelling air which has given
me headaches. itchy and Irritated eyes. and sore-r ihroain. ihove iafl work early a few days to work oi home

 

because it was so bad

 

 

 

 

 

 

 

 

 

 

Did injury occur on campus? Yes No Campus location where injury occurred If not on campus, name 3; address of 51m
C) SDSU - PSFA
llama 8r. contactiniormation of With ass: None Was another horror: reaponsible? Yes No Were other employees injured? Yes No
-

by. Name 84 canlact information of responsible party? Wore Campus Police noti?edDid the employee miss any work minted in the injury? No Yes lives, Date: Time From: To:

 

    

la

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.anSDi -

 

 

 

 

 

Medical Troatment Required 

 

.Medlcal Facility
C) Sharp Rees-Stealy

   

 


if nihor. please complete tho following:

 

       

  

 
 
 

 

 

Safety Guidelines Deweloped
Training Scheduled

 

Employer." Counselad Safety

Repairs Ordered

C) None 0 Emergency Room Physician/Fa Name:
0 Flat Md 0 Hospitalization Other Address;


0 Medical are Phone:

lJl. ?Ll ?3 '1},er W0 It?s '53 lbw-l-I 5?0'1" 3  - - 
9.ACUON 
?@9335 57133? be taken to prevent recurrence? Check as many as appropriate

Personal Protective Equipment Ordered

women 3914 ll"?

 

 

 

 

Completed Bv [Print Name) i
1*



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Signature



Mu.

. .31 It?d
Date



 

SAN Dliiti'OSl'ATir'

Please fax to 619-594-4013

REPORT OF WORMELATED 
Complete this form' in its entirety and submit within 24-hours of the inju

SIJ Crew" n+?5w4utfl

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

?type of Injury



 

Aztlan Causing Injury

Du 9V Biennium??

 

Eontributing ObjectiEquipment



 

 

UNIVERSITY
File as: Date of injury! Time of injury
0 Worker's Compensation Claim 03/ 0 4? 2/0! 0 am. 0 pm.
Filnddem Only Report Supervisor's Date of Knowledge Date Given to EmpIOyee
EMPLOYEE 
Employee?s Name (Last, First) Red ii) .. Primary Phone 
. I ?m 
Department A, 4 Email
- JP
or . . n'uvl 6
Supervisor; Na me I Supervisor's Work Phone Supervisor? Email
Hours Worked For Week: Days worked: M- Th 5 Start time: 6am 7 End Time: 0 am.
anwm?uu (Mo ova-m- 7 ion-m
INCIDENT 
Injured Body Part BACK OF HAND FRONT OF HAND

 

{circle injured part}

 

(circle lnjumd pan)

 

 

Left

 

 

 

Right

 

Right

 

 

 

 

 

 

 

\b?escri?ein? detail how the accident occurred Eni'pioyee was opening a box and the hex cutter slipped lacerating his left thumb 

MumWi? MWan

W?wm?j



 

Did inju'ry occur on campus?

Campus location where iniury occurred

 

If not on comp??s, name&addressof sit? 1 (Ch .

 

 

 

 

 

 

 

 

Name contact information of Witness: None was another person responsible? Yes No Were other employees injured? Yes
0 0 
. Name 8r contact information of responsible party? Were Campus Police noti?ed? Yes No
0 0
Did the employee mis; any work related to the injury? No Yes If yes, Date: Time From: To:
MEDICAL INFORMATION
Medical Treatment Required Medical Facility If other, please complete the following:

None 0 Emergency Room
0 First Aid 0 Hospitalization
0 Medical Care

0 Sharp Rees-Stealy

Other

Address:

Phone:

 

 

Physician/Facility Name:

. A

 

CORRECTIVE ACTION

 

Supervisor's investigation: What action will lie taken to prevent recurrence? Checkas many as appropriate.

Safetv Guidelines Developed
Training Scheduled

Employee Counseied Safety

Ila-pairs Ordered

Personal Protective Equipment Ordered

When

We 355:0"

 

 

Completed By (?int Name)

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Date {?42123} l4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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3 .
. 1 . REPORT OF 
i? Complete this form in Its?eniirety and submit within 24~hours of the injury
SAN DIEGO Sums Please fax to 619~594~4013
UNIVERSITY
Fileas: Date of Injury Time. oflniury
Worker?s Compensation?Clalm .79, gold AVA om. 0 pm.
incident Only Report Supervisor?s Date of Knowledge Date Given to Employee
#74}
EMPLOYEE INFORMATION
Empioiegz?s NamgiLag. First) Red Primary Phone
Deparyem? Email I 
Supewisoi?s Name A A . Sup'?fwisor?ws Work Phone Supervi?or?s intuit 
. i .
Hours Worked PerWeeiu . Days Worked: "in s?t?'rt time: 0 a m. End Time: 0 am.

INCIDENT INFORMATION
inlured Body Part" BACK OF HAND FRONT OF HAND

{click iniuntd part)

 

 

Left

 

Left

 

 

Right

 

 

 

 

 

7

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of 0

Ma?a?
VA WM JMJIM

Campus incatiun?where injury occurred

 

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Name 8t contact Information of Witness.

Describe in diatail How the acclu?ni occurr?d ii a. Employee was opening a box and the box cutter slipped lacerailng his left thumb)

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us, name 8. address

 

 

None Was another person reSpon'sitii??i Ya: No Were other employees Injured? E, No
Name contact information of responsible party? I Were Campus Polite noti?ed? Yes No

 

 

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Did the empiaye??iss any 'worlc relate}! to?tiie {aims

NO

05?

Yes If yes, Date:

Tim? From: To:

 

Minimymonmmlou

 

Medical Treatment Required

0 None 0 Emergency item
0 First Aid 0 Hospitalization
Immune: Care

Me'dical Facility

 

0 Sharp Rees~5teaiv

(X Other

 

Ii citizen-please complete the following:

mama:
Address:
Phone:

 




ACTION

 

[3 Training Scheduled

 

Safety Guidelines Developed

Employee Counseled Safety

Repairs Ordered

Supervisor?s investigation: What action will be taken to prevent recurrence? Check as many as appropriate.

El Personal Protective Equipment Ordered

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Rev. #231113


 

 

SAN Dustin ?i'lWl'l

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1
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REPORT or 
Complete this form in its entirety and submit within 24 hourn of the injury

 

 
     

Employed 5 Name (Last, First) r1

 

 

  

   
     

 

     
   
       

ll Summit? 
"7 .
File as: Data at injury Time of injury ?9 ?In ..
C) Worker?s Compensation claim {719pm.
incident 0m, Report Supervisor?s Date/f Data Given to Employae
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Department Job Title (In. Student Intern) Email I
. . A 
Supervisor?s Name Supntyisor?s Work Phpna Stiperyisor's Email Supervisor?s Fax
Hours Worked yer Week: Days Worked: libs 'S?tarttime: it? a In. End TimeJr?s; 4 ?mm? me.
Qpi; I I ,1 4" "4 THY *hmt 
- . v- dam 11c mm. 30- MO it}. . - - 1
injured Body Part (clitlalnjumd part} BACK 0? HAND FRONT OF HAND
3 icirciuiniurad PM) (Circle iniuracl pant

 

 
  

       

 

   

 

Type at in

(Low

bi' mm) {Jilin-?13 {2,41

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Actlo Causing i

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Object/Equipment

      


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Ve/?i lg?hJ? Left Right - Left Right
Describe in detail how the accident occurred i..e Empl yen aso enin abox ox utter slipped lacerating his leftt mb?) {?33
(?or 3? $215 5?13 [3 QC) l?t ll '1 ?1911" Carma?
my :tc 1A Ht) \Hmf?l?
Beam ?Elati' anti IM My til/Irvin WW I II unlw'n'p inlay/1i 
Did iniury occur on campus? Yes No Campus location where injury or taut Ilm campus. name 8t addicts of 5th -
0 FA buci?iry?)
Name at contact information at Witness: an Was anothar arson res onsiblej? Yes i No Were other employees injured? as No
(limit in I 0 0
Name contact information of responsible party? Were Campus Police notified? Yes .No .
0
Did the employee miss any work related to the injury? No Yes If yes. Date: Time From: To:

 

$415!
1.1
if.

0 Sharp Rees?itnaly
0 Emergency Room . Physician/Facility Name:
0 Hospitalization Other Address:
0 Medical Care Phone:
iis.? W11

m?WSh 

Safety Guidelines Dayeloped
Training Scheduled

 

  
  

Medical Treatment 

. 
?75313114384. tL.? {3333' w? gray-it"s?
Supewisor? investigation: What action will be taken to prevent recurrence? Check as many as appropriate.

91? 
my yiymr-emfajw?x}. ?ng355 {Ri?e 
Medical Facility

  
 
  
  
 

     

4m 3233,Eaii?ii?rmif; ninth 
if other. please complete the foliciwing.

       
   
 
 

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. 3:51am 3-331 2
it? 

 

Employee Counseled Safety [3 ?ersonal Protective Equipment Ordered

Witter: 28? 05665 at

Repairs Ordered

 

 





I 

4 (Oi
CoiII?pleted Bylirinttiime) . . Simian? "m



 

suvenvrs?on?s REPORT OF wonmemreo 
Complete this; form in its entirety and submit within 24?hours of the injury

 

SAN 0mm S'l'A'l'ii Please fax to 619-594-4013
UNIVERSITY
File as: Date of In ury Time of iniury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contributing 

 

  

 

Worker?s Compensation Claim ?Incident Only Report Supervisor?s Date of Knowledge Date owcvz Given to Employee
EMPLOYEE INFORMATION
Empioygg?s Name (Last, First} A . 'Red ID priimm ?Wm .. A
W, WNW
Depamenif A ?oh Email A
- I:
. 
Supervisor's Mamet Va?upervlsor?s Work Phone ?ipewisor?s Email A 6? 
Hours Worked For Week: Days Worked: ?r Th Start time: 0 am. End Time: 6 am
HO ow: oli-m
.
?injured Body Part (circle lr'ilured pm} BACK OF HAND FRONT OF HAND
(clinic iniurod pan) (circle iniured can)
3
(IA com MM
Type oTiniury
Action Causing injury

 

 

 

 

Loft

 

Right

 

 

Left Right

 

 

 

 

 

 

 

Describe in dotsll how the accident occurred 9. Employee was opening a box and the box cutter slipped iacerating his left thumb.)

CLW olizmalw I big/Rf ?queeo/I 



 

 

 

 

 

 

 

 

.

 

 

0 Sharp Roes~$tealy

 

Did lnlury occur on tampus? RN13 Campus location where injury occurred if not on campus, name at address of site (I
Name a contact information of Witness: None Was another pe'rson responsible? Yes No Wore other employees injured? Yes No

Name nomad information of responsibie?par Were Campus Police notified? Yes No

0 0
Did the employee miss any work related to the injury? No Yes if yes, Date: Time From: To:
5" 
MEDICAL INFORMATION

Mcdioai 'rr?atment Required Medical Facility if other, please complete the following: 

 

None 0 Emergency Room Physician/Facility Name:
0 5 5? Nd Hospitalization 0 Other Address:
0 Medical Care Phone:
CORRECTIVE ACTION

 

Safety Guidelines Developed
[3 Training Scheduled
- 

 

CI Employee Counseled Safety
mli>nint0rdomti

Supervisor?s Investigation: What action will be taken to prevent recurronce? Check as many as appropriate.

Personal Protective Equipment Ordered

at: i
minim: $5.40?

 

 



Bi'r (Print Name) 



"f


Shg?wkl -





 

 REPORT 09 wonlmemriso 
Complete this form in its entirety and submit within 24?hours of the injury

I

 

 

 

 

 
   
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

     

 

 

LIleattSI'i?v
. \i 
File 35: . Date of injury QJU 1 Time ofinlury
Worker?sCompensatiovv Claim E) a..m Q) pm.
lsov? 5 Date oanowIedge Date ow 1 SW to Employee
Incident Oniyitepovt Sum WWI 511
.153; 4 9. 4-3- W7 .9155 at?? ?q @9659 3?11??
332?: ??aws? .43: ?3?th ?if .3: ?.233 "11' ?hi ii; .41? . ii. 
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Employed sNameitast, First) find it) Primary Phone
Department - Email Supervisors Namn - Supervisor's Work Phone Supervisor's Email -
WW 
PerWEek: DavsWorked: Th am. End Time: 0 nm.
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A. 
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Iniured Bari? Part BACK OF HAND OF HAND
. pail) (clvdainiuratlmri)
i
Type oiinlury 9m
E: i

AnionCauslngininrv

     

Contributing Object/Equipmant
buxiae?vb

Describe in detail haw the accident occurred (Le. Em wassopenlng a box and the hex cutter slipped iaceratlna his left thumb i

Wm Ni? 49:] PgrA W4

WWIWQ 1 

 

 

 

 

 

 

Left Right Left Right

 

 

 

 

 

 

 

 

 

 

 

 

 

mdlniuryoccurti?campus? Yes No "iinotbn campusmame??atidmssoislte
in 0 
Nameitcomactininrmation oiWItness: None Wasanuther person responsible? Yes Ware otheremp?inveeslniuvedparty? WereCampusPoiice notified? Yes No
'No Yes lfy?smate: ilme min: To:
.zc 3i r. 'f giftfin- biglf?ifii-R .. i ?kw
Medical Treatment Required Medical Facility ?other, please complete theftiliowlng:
Sharp nees?Stoaiy
Nona 0 Emergency Room Physician/Facility Name:
0 Other . Address:
til I
ca Cave Phone:

 

?Vngv-L -. 4 "tr? i. .- 4 . 
?it. ?ii 9E5 Ill a?Ai?f?l?l'g 3 .2 HM.
Supervisor?s Investigation: What action will be taken to prevent recurrence? Check as manv as appropriate.

 

 

 

 

WW Guidelines Developed Employee Counseled Safety Personal Protectlva Equipment Ordered

[3 Training Scheduled Repairs Ordered mower: .

 

 

 

i ?lvi



Completed By (Print Name) Slaw Date

mid 5194?? 5;!qu Remnant 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

it"? REPORT OF WORK- RELATED 
. Complete this form in its entirety and submit within 24 hours of the injury
SAN A Please fax. to 819 5944013
my; 
File as: Date of injury Time oi injury
QwOrker's Compensation Claim U?m .. Fm 9,015} 0 am. 0 p.m.
I Supervisor?s Da of Knowledge Date 0 Cal Given to Employee
incident Only Report
ole?? I9 5? will?
EMPLOYEE .
Employee's Name lLost. First} Hume Phone Cell Phone - Work Phone
Department Jot; Email '1
Superyisor's Name 'Suporyisor?s Work Phone Supervisor?s Email Supervisor?s Fax
Hours?wiorited Per Wooll - ?Doys Worked; [gig]? Th F, 5 Start time: 0 am. End Timemom 
injured 806v Part - BACK 0? HA ND FRONTOF HAND
. pant Icirtleiniwod part)
Type of injury .

Action Causing injury 

 

(911$ vim) ?2

 

 

Contributing Object/EquipnIeIIt

 

   

 

 

 

 

 

Leit Right Left Flight

 

 

 

 

Describe in detail how the accident occurred ti. o. Employee was opening a box and the box cutter slipped laceration his left thumb 

 

 

 

 

 

 

 

 

 

 

 

 

I I 
It: ?my on i ?win
Did injury occur on campus? Yes No Campus location where injury occurred If not on campus, name 8? address of site
. ?1 
3 l, 
Name 8: contact information of Witnes?: None Was another person responsible? ?Yes No Wore other employees injured? Yes 8:
ob. . 0
Name contact information of responsible party? Were campus Police noti?ed? Yes No
Did the employee miss any work related to the injury? No Yes if yes. Date: Time From: To:
i INFORMATION
Medical Treatment Required Medical Facility if other, please complete the following:
0 Sharp Rees-Stanly
6 None 0 Emergency Room Physician/Facility Name:
OHospltalization Other Address:
0 Medical Care Phane:
CORRECTWE ACTION
Supervisor?s investigation: What action will be taken to prevent recurrence? Check as many as appropriate.
Safety Guidelines Developed Employee Counsoied Salety Cl Personal Protective Equipment Ordered
Training Scheduled [3 Repairs Ordered waiter: 

 

 

 

 

Completed 8y (Print Name) Date A

new. 4/33] ?l

 

 

 

 REPORT OF ATED ILLNESS
Gornpio to this form in its entirety and ouhmit within Murmurs; oi tho injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 

 
   

UNlVl'lih?l?i?r?

Filo as: Date of Injury Time of injury

0 Workor's Compensation Claim 2/2711 9 arm. pm.

6) ncidont Only iloport Sunorvlsor?sDato ofKnowledge 113;!" Lil? 

1130/1 9 _ZWi?i
INFORMATION
Employoe?s Name (Last, First) Home Phone Call Phone Work Phone 
Department: mm lob Titlo nu. Custodian. Student Intern) Email
HTM 
Supawlsof?s Namo Supervisor?s Work Phene Supervloor's Email ?mgup?rvlsor?s Fox MW
Hamill/mm PerWeok: Days Worked 5 Th 5 Starttime: am. End time: 
[:11 8'30 0PM 4:00 .iim

puny-p, 33"5133. "ii. 22 i. 1? 3.1.3.3. as; 

 

 

Injured on Part irimiemiredrarti BACK or HAM) room or m3

{circle iniumrl purl) {Clmla Inlumd pun;

\llil

    

Head. eyes. throat

 

Type of Injury
Pain and irritation

 

 

Action Causing Injury
Chemical fumes

 

 

 

Contributing Object] Equipment

 

 

Left Right Left Right

 

 

 

 

 

 

 

 

 

 

 

Describa In detail how the accidentoocurreri lie. Empioyea was opening a box and the hon cutter slipped locarating his left: thumb.)
Strong fumes from the roof work being done in the building has been causing hondrachos and allergy type 

 

 

 

 

 

 

 

 

 

   

 

Did injury occur on campus? Yes No Campus location where injury occurred if not an campus. name address of site
PSFA
Name ii: contact Information of Witness: None Was another person responsible? Yes No Were other employees injured? Yes No
(E) 
Name contact information of responsible party? Were Campus Police notified? Yes No
u- or Q)
Did the employers miss any Work ralatarl to the injury? No Yes If yes, Date: Time From: To:
(9) We? ve been released early or fowlrg

1., :31.2.- MliblCAl. ?ii-ir- .. .. 
Medical Treatment iierprired Meclirnl Facility if other, please complete the following:

0 Sharp Rees-Stealy
None 0 Emergency Room Physician/Facility Mama:
0 Hospitalization Other - AddressPhone:

 

 

 

common: Aaron .-. -
igniting Q?r??glhiiostlgation Mongolian will be taken to prevent recurrence? Check as many as appropriate

 



 

 

 

 

 

[j Safety Guidelines Developed Employee Counselod Salary Personal Protective Equipment Ordered
Tm??'ysmedumd Repairsordered [gloom {?2,106an 

I
. .. 

  

 

 

pram.

Date

. Rem-I123!?

3? Compioted Byl'lirlnt Name] 5min};