Employee's Report of Accident
REPORT OF JOB ACCIDENT: Employee’s preliminary report of work-related injury to employer.
Date of Report : _1-2-1933__________ Rpt No. : __150267___________
Report filled out by __K J Ale_________[name]
__14 Mont Ave. ___[address]
The following employee reports an injury sustained in the work-related accident described below.
1. Employee name __Brian Lumley_____
2. Employee ID __1237BL__________
3. Designation __Lead Machinist_______
4. Employer Name __Nines Corporation_____
5. Employee address __4782 West Look St._
City __San Jose______
State __CA_____________
Post Code __95126_________
Phone _n/a_____________
6. Date & Time of Injury ___12-16-1932____________
7. Address/place where injury happened __Main Workshop-A1_______
8. Description of injury and part of body affected __Leg broken_______
9. Signature of the Employee ______________
2. Employee ID __1237BL__________
3. Designation __Lead Machinist_______
4. Employer Name __Nines Corporation_____
5. Employee address __4782 West Look St._
City __San Jose______
State __CA_____________
Post Code __95126_________
Phone _n/a_____________
6. Date & Time of Injury ___12-16-1932____________
7. Address/place where injury happened __Main Workshop-A1_______
8. Description of injury and part of body affected __Leg broken_______
9. Signature of the Employee ______________
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