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Get UTD Sharps Injury Form Needlestick Report

Investigation reports. Employee Information Employee's name: ______________________________________________ Male__ Female__ Date of Birth:____/____/____ Home telephone #(______)_____________ Home address:_______________________________________________ City:_______________________ State:________ Zip Code:___________ Present Classification:_____________________ How Long Employed at UTD:___________ Social security No.: _______-______-_________ Weekly pay/salary: $___________________ Vaccines Rec.

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