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Get NY SCA Incident Report

(refer to columns/beams/drawings, as needed): INVOLVED PARTY INFORMATION Name of Individual / Company: Address: Phone: Is this a work related injury? Male Female Employee Job Title / Occupation: Employer: Employer Address: Supervisor: Email: No Date of Birth: Yes If yes, complete this section SS # Length Employed: Supervisor’s Phone: INCIDENT DESCRIPTION Describe in detail how the incident occurred. For Bodily Injury, describe the task being performed by the involved party when he/she c.

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