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Get IL Employee's Incident Report - Effingham City

Tions carefully and make your answers complete and accurate. RETAIN ONE COPY IN FIRE DEPARTMENT – FAX ONE COPY TO THE CITY HEALTH & SAFETY INSURANCE COORDINATOR EMPLOYEE’S PERSONAL INFORMATION LAST NAME: FIRST NAME: MIDDLE NAME: STREET ADDRESS: CITY: STATE: HOME PHONE: CELL PHONE: DATE OF BIRTH: GENDER: ZIP: WORK PHONE: SOCIAL SECURITY #: JOB TITLE: YEARS ON JOB: SUPERVISOR: INCIDENT INFORMATION TIME OF INJURY: A.M. ‰ P.M. ‰ DID YOU IMMEDIATELY REPORT YOUR INJURY TO YOUR SUP.

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