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Employee Incident/Accident Report 3-Part Form

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MPN 2117/3
Packaging 1 per each
Size 8 1/2In x 11In

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    Part 1 of this form captures the data necessary to adequately evaluate all accidents and incidents in order to determine what (if any) action needs to be taken. Parts 2 and 3, however, are designed specifically as the communication link between your facility/ agency and the health care professional in the event that medical help must be sought. The top portion of Parts 2 and 3 record all of the information about the incident you are required to submit to the health care provider. The lower portion allows him/her to report back to you. All information requested about an exposure incident is conveniently printed in red ink.

    8 1/2" x 11", 3-part snap set, color-coded copies, Part 1 prints different from Parts 2 and 3, red and black ink (all parts), wrapped in 100s.
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