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Part I – To Be Completed By Injured/Ill Employee/Volunteer Employee Volunteer Student Employee Name of Injured Person: Home Telephone: Home Address: City: Zip: Date of Birth: Employee : Work Location: Campus Department: Job Title or Occupation: Average Hours worked per week: Average hours worked per day: M T W Th Fr Sa Su Employee’s Supervisor: Department Phone : WHEN AND WHERE DID THIS HAPPEN Date of Injury: Time of Injury: Date Reported: Time Reported: Location of Injury (Campus) Exact location of injury (Building, Room ) (If injury happened off-site indicate location, address, city and zip:) HOW DID THE INJURY OCCUR Describe what happened and what you were doing just prior to the injury..
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