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E submitted to the Associate Dean for Clinical Education (or designee). See Policy #302. Today s Date: Date & Time of Incident: Location of Incident: Student s Name: Faculty Member s Name: 1. Briefly describe the incident (who was involved, who was present, who was notified, what happened, when, where). 2. Was the student or faculty member wearing gloves at the time of the incident? Yes No N/A 3. Was the student or faculty member wearing goggles, a face shield, or a face sh.

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