ࡱ> ~y !7bjbjEE .N''L A ))yyy<lD= $   % $!#######&Y)6#iy"N""#)) %yY$V#V#V#"()8 y%#V#"#V#V#aV# 6`"XV##o$0$V#)#F)V#)yV#""V#"""""##V#"""$"""")""""""""" :  EMPLOYEE ACCIDENT/INJURY REPORT  SECTION I: EMPLOYEE DATA Name of Injured Employee (Last, First):  FORMTEXT       Social Security Number:  FORMTEXT       Department:  FORMTEXT       Employee s Job Title:  FORMTEXT        section ii: details of injuries Describe the injury in detail and indicate the part of the body affected:  FORMTEXT       Did the employee go to Bennett Infirmary? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Did the employee go to another physician/medical facility?  FORMTEXT       Name of Treating Physician/Practitioner:  FORMTEXT       Name of Medical Facility:  FORMTEXT       Treatment:  FORMTEXT       Was the employee admitted to the hospital? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, date of admission:  FORMTEXT       SECTION III: EMPLOYEE S STATUS Did the employee miss time from work? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Date the employee returned to work:  FORMTEXT       Date disability began:  FORMTEXT       Number of days of lost work:  FORMTEXT       Probable length of disability:  FORMTEXT       SECTION IV: DETAILS OF ACCIDENT Date of accident:  FORMTEXT       Time of accident:  FORMTEXT        FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m. Location of accident:  FORMTEXT       Accident was reported to:  FORMTEXT       Witnesses to the accident: 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       4.  FORMTEXT       Description of the accident: 1. What was the employee doing just before the accident occurred? FORMTEXT       2. What direct HJLNP : < ғwgYHYwY:YjheUmHnHu j{^he5CJUaJjhe5CJUaJhq}he5CJOJQJaJ%jhe5CJUaJmHnHuhe5CJaJ#hYohr 95CJ0OJQJ^JaJ05jhr 95CJ0OJQJU^JaJ0mHnHtHu#hr 9hr 95CJOJQJ^JaJhr 95CJ0OJQJ^JaJ0 jhuh|UmHnHujhr 9UmHnHuJL t,667777Lgd7gde dgdr 9< P R T ^ `    L N R ~vdULhq}5CJaJhq}5;CJOJQJaJ"hq}hq}5;CJOJQJaJhq}CJaJ"jhCJUaJmHnHu"jh*CJUaJmHnHu j_he5CJUaJ jc_he5CJUaJ%jhe5CJUaJmHnHujhe5CJUaJ j^he5CJUaJhe5CJaJR r t v D F H \ ^ ` ܯӥӖrm_N_ jah5CJUaJjh5CJUaJ hq};"j3ahq}hq}5CJU"j`hq}hq}5CJUjhq}hq}5CJUhq}hq}5CJ%jhq}5CJUaJmHnHu jK`hq}5CJUaJhq}5CJaJjhq}5CJUaJh5CJaJhq}hq}5CJaJ` j l n  R T V j l n x z | "кЭкБЊкsЊjch;Uhh5CJ h5CJjbh;Ujh;UmHnHujbh;Ujh;Uhh5CJaJ h;h5CJaJjh5CJUaJ%jh5CJUaJmHnHu'"$@BDFPRTprt.0ΡΒypdTGhN,5CJOJQJaJhN,hN,5CJOJQJaJhN,hN,5CJaJh5CJaJhq}hq};!jh5CJUmHnHuj_dh5CJUjh5CJUhh5CJ h;"jchh5CJU h5CJ"jwchh5CJUhh5CJjhh5CJU0.02FHJTVĸݦĸtctR jfhN,5CJUaJ j3fhN,5CJUaJ%jhN,5CJUaJmHnHu jehN,5CJUaJjhN,5CJUaJ"jIehhN,5CJUhN,hN,5CJaJ hN,5CJ"jdhhN,5CJUhhN,5CJjhhN,5CJUhN,5CJaJ "$jl"$RThjlvxz|ּq`qQjh*h*5CJU j hh*5CJUaJ%jh*5CJUaJmHnHu jgh*5CJUaJjh*5CJUaJh*5CJaJh*h*5CJOJQJaJh*5CJaJ jghN,5CJUaJhN,5CJaJ%jhN,5CJUaJmHnHujhN,5CJUaJ|   "$.0jl 2˫˚˫v˫e˫ jUjh*5CJUaJ jih*5CJUaJ%jh*5CJUaJmHnHu jiih*5CJUaJjh*5CJUaJ"jhh*h*5CJUh*5CJaJjh*h*5CJU"jhh*h*5CJUh*h*5CJ 246@Bpr*.*0*D*F*H*R*T********ŴţŒŐn jmh*5CJUaJ jlh*5CJUaJU j-lh*5CJUaJ jkh*5CJUaJ jAkh*5CJUaJh*5CJaJ%jh*5CJUaJmHnHujh*5CJUaJ jjh*5CJUaJ)ly produced the injury: FORMTEXT       3. Describe the events which resulted in the injury:  FORMTEXT       continued on next page SECTION IV: DETAILS OF THE ACCIDENT CONTINUED Unsafe Conditions: What was not safe concerning the machine, tool, equipment, premises or vehicle? Why did the unsafe condition exist?  FORMTEXT       Unsafe Acts: What did anyone do or fail to do that led to this accident? Indicate reasons for unsafe acts:  FORMTEXT       Recommended Action:  FORMTEXT       What action has been or should be taken to prevent a similar accident?  FORMTEXT       SECTION V: REMARKS  FORMTEXT       SECTION VI: SIGNATURES _________________________________ ______________________________________________________________ Date Signature of Supervisor Position/Job Title _________________________________ ______________________________________________________________ Date Signature of Employee Position/Job Title *Attach statements prepared by or taken from the employee and all witnesses Use this space for diagramming the location of the accident, position of injured employees and others involved, location of equipment/vehicles, part of vehicle involved, etc. For Exempt and Nonexempt Faculty, Staff and Service Personnel *+F,r,t,v,x,|,,,-0.2.F.H.J.Խsh]M]:M$jmh*C5CJU^JaJjh*C5CJU^JaJh*C5CJ^JaJh*5CJ^JaJh*56CJOJQJaJh*5CJOJQJaJ-jh*C5CJOJQJUaJmHnHu-jhO5CJOJQJUaJmHnHu-jh75CJOJQJUaJmHnHuhe56CJaJh*h*56CJaJh*5CJaJhN,5CJaJJ.T.V.N/P/d/f/h/r/t////////000000000000000111ϼϩϖڋ|i$jgoh*C5CJU^JaJh*C5CJOJQJ^JaJh*5CJ^JaJ$jnh*C5CJU^JaJ$j{nh*C5CJU^JaJ$jnh*C5CJU^JaJh*C5CJ^JaJjh*C5CJU^JaJ)jh*C5CJU^JaJmHnHu"1:1282F222223333 44*4T444,505666кެОГvi[I"hYohh56CJOJQJaJh7h*5CJ^JaJh756CJ^JaJh7h756CJ^JaJh7h7CJ^JaJh75CJ^JaJhOhO6CJ^JaJh*Ch*C6CJ^JaJh*C6CJ^JaJhO6CJ^JaJhOh*C6CJ^JaJh*C5CJOJQJ^JaJ#h*Ch*C5CJOJQJ^JaJ667777Lh5h7h*5CJ^JaJhr 9hh"hYohh56CJOJQJaJhh56CJOJQJaJ21h:p3/ =!"#$% {^Dd0*  vA?UNA_LOGOPicture 0UNA_LOGO.gifb]UR7DK-n=i]Dna]UR7DK-n=PNG  IHDRD6vPLTE!!!)))111999BBBJJJRRRZZZccckkksss{{{ֽƽ{ss{{kccZRRcZZJBBB999111)))!!޽ƽ{{sssk{kkcZZRccZRRJJJBBB999111)))!!!7vtRNSS%bKGD cmPPJCmp0712HsXIDATx^} c#Ǎf7EDDg{}I|s2#ۙof6]@ MvSx؏j| v10@u 3@40'p|D 3p :pˇ@40'p|D 3p :pˇ@40'p|D 3p :pˇ@40Df'9FWEs 3t2;FfW Ɂ e@DI#Hi`p0{@ Dbt 3VB-.׈% I f| $| 3 Dv{bp0{3 O7szˆ(@  5瀢, g9VCu)!eAW'yƈ51GΖe0btj1Ky5놜.i h^^ͻ=㶪[v@<.ZuZ=b8YWϏv, MuAa= %ث6L]O-?7>-dˣI{Jxm'*_v#"ᏐjlW7ې?_#8zfqz}3,Ŀ{wx_|߁jxfV)a {lfP $b d2}'y0s䗂#U_m7Cu,a=`JV&[Bݦ&^Gck_B5ۈ}q_9N.wg\7\|TM 2VDp 0ݥծId8ƙ8bל\We痔:D3Vz\3l4^̆hPkzc<,#C|ZAU/1+^-5s?T0)f@$K2*DA΍~cA5^[(D:"ک*Ae<om'bc+≑zSr)o*ضJ(VgIF"{KM4>ž wNV DVmY|BC"7'Xعus QX-γs} .O"򁢕̥ex4J5 "O*'`0}0.p$i%~bKmM$B@Q:hQYEv[-z>2@RWӟqh ݂už |*RgPT& ]&VR"K,H/8 Ah!ܘĊG4`UsEvAd:eQtD;ߜ7/HHVdNDdѕ<PB2",(DT/"e L{4M$U;VbAG&TA("I" OAy_~_Ź =h,5JBa8>.F" ԚQ="v:"d?<ol[ 4'X9"6/Dj0lL2@t'6wj8z [=&v;<2ݗ,KÊ 6h[y^H&Exy;SzH\.6"vg}s ";r"o$QΖTTD¿i "o)F`)^ASH 9Ѓ%sohP8^7d.Hl "ϟ{І\Ik aLz|,=*t3Qޝ+G$ ʦ*5 K \H;.e eM}ݲM3`\Q;u̹@=Ts\Bcn B# Z򯲪SaR^XUSihǼ[7R \?|c1?$9tԪ"! w G6jAoni`44BmyөobtMP"ߘ{}x9azY !MzdA Ju5ۃf3%nmlj7.7D(&,WVw}Ku>9%I v[5D)A Jt:|$2sKeՅ\#*\ꁨ2W&꧍26] >\Yye9O@"/FםRa W*m.Yi(5uYZu,}PduR5sϓV -cXK,EztT S,@™RvqW>zV" I0&Q  U[0sGnp soS%2tKNDv@he O/&3j`EE{VA{>q7cĉN6ܱAcL*ݛѝvkPI΁ xba ;׬fA$J)2,N7$<& 3wdePS/LUݣ4@X&@j"U3.8*K6ߊA"ta~rQ@y6lԻ'ׁ;$yu5$#AUNDzyȷ$r;[y W ֲcx〨^ KA=ed/䗢'׺?!rKiql%3s<ѐ.GhF `؃"1<ԵAw* mSDDPD2l;' ~HL KX3">t?녭?"6a rj֕AJl,0b& cnlDR#:@_x D{T"r[ Aڇ.;< K7"(gDZlwt"!_DUt7U=R2W"N=)h"z&]YFߋ _ JHo1}x"0[z'n_١8 "2N0p^pȫ"8Ăl+Mx6m-b$и /@m9o PڵD2?:E lMD= "KT\vNȢϢ:Jq^kjD`Cucj D!Mh#hIccW/Dz9.vNG#9 #a ZgGmBGozQAֿ/ϼLkn?++&V xy BWv "H.DwԢBOEY y&$̅t2UmnPD'dp9)]œ,j\Ho"X 51"2j*"ܦtO^@ejמ 1lc̉+Ӝ ퟥS%t,vJ B-m\}A$ګKʑ}x,ҹ<DDCaJ_tuzeD@ sK%jc> H,HyZd^hot#pRxFprsc=]C#P~n߽R:PG@oanW!y!r`vn؇~?QKQ Bx%)^Z9 t[)"0F_E0!ۊm4PHB B5] T 9;4sȁ(jMT6*__nyV$6;*{>A?@`ek5GAIENP\|Ҏ+QD1D?--Lˆh6| %U*eAɅAl4Oe@+*Rtֱh-zAd#=t\DUHW{Dv =W(P^1xqr;&hӜ.HH} }PrgMxa)n[ 3`FWZC6ƚ) SdO, -F.=ֻNe]Dqiv])m|w~>NCD|#rz<*ӟ(E#f_!ɒ yR r[fQ-]rI|!X~5 * 16v*'3ἹʴTc!&>L{@kS3(-< @)C%R,Kka6kF1\oW" ҎlxkXSh9Ɣ8Ѝ):OUb4J֡~5&qRg"JT P#0^BbZ}T[}016jT0H Ef]c}zx]X@2&^"0o*C# +ooS|zQR"9ZWQ/Vq=ír@@lvr 0t2Fz T Y.nVP4̦@ Gf4FݎRYm.#qb/pR8Es0Yn|d%Zܩql6+ЂH^;Vћ {ps%Plo&6wekK2~'>Hx\ZZɏi ?Rch DԜ+g(@$0/]>9'&ߣ"Ѥ~!C)6UN0F9BUv=#($jnA)GAdEb+=Or$gWX?8hSt?Mafᛔ2Mp /}l=L6OO}6Wa[g ?.;F\ycٍ_ʀkM^)iH"E/8z ]vD184V _Tkǘ";eH|u\L^ _#y7ħ%yre+o}RpZs|2-Q^7x@ (1`\fu9qj_ڵY"> ]ĠDdo۔}O Pz9 6"  KY{H RqF=̖y&L6go_w3e5gJIw'piįo:SO BJ L)A6^x\ EvmqO &Zr;\% @6c'kM4H3Ћ&rBe 3_}H<젳u-BzѹX<8pHEBIDw=T+_dV%ed~ Z"a*ū`=CvL h}b/yD[xlHk꯽+! y\d\*X҈Z #[3+z+lo52~ᲺWNqhz ::Ĥ2*8%c~ݍܹW}+r͟T X[S DJ4}q 7P3P!@Z ރ_=s2%.]4PYb ɝ_lz`4@ù>~v,Et>?+Z0_4u;F=twEJoՠAxiŕQa 2vE6A}mr CiGG~xO jTGrm!aNDK2U ocޥ*NEߙL*Žj>/wiW(iD _ũe/mu"c/&= to3_̒$X[,}^ԽU*HdtYEsyoZdߊ(P@iv'D΍Z\ NV! rtM\=Ĩ%v\.pkR~sAPשdz45ZxSFu5^QJ4q+E"݉ҙٶJ3L~Z_q t\*څ y37ghJD|):5799՜)@Md{/$d? ףq [®D[iUSٕ5 DPI]bxce4L3qVmp% &9ߖE- %y=cbT)Aj [8t[M9y 'H3.[P/`>\os{țy.^OS=XP*‹nQD^ @j9M17,vw$y 8p=}^9mK:0L'8!!"}a̓KyI*h]~D&SD;xO 4Q!AtACWigsROLAX3KiDeb "\o =mlS`ȗat!@֎`@D ?7H"!ea#OCGW&(P JbXM~m\]VC_xO킘+ lr-6 sgYDGn>Z &t_(Z>@DfoZ 7łje(EG}/+1){$K|dA>7%{}'^O/G2ѝBNnܷ0{}0 P pE*CH.h)/]AwNQDũmR7 DƉF$GUݤɉB$ev:>轮C6Lcn!OV}Ad 5ц b7f_e%AH.,#Y$A@B&+~At+ 1gfw7QձG. e}dkwxzՒzDdìSo„G!ly Y.{5vHe%r@ ^cDBE]}lWRG#_MK_?aYjW}RO ZYi18#O%pbt`k@^E8GB8"dwi99קOd "^֗ JU݈Q~O 5H'Li?.d~RDO E䵚o L.gHtp"\}Xv!U{%4Qct7Wʎ#$?c+Ia ޼]A`LB0#@`8Ek55pD+AD0ź&*T9NHf7`~ ͹PW_B}"Wxs$囗I$^&JRx 7͌[_}lx4e)Y=D"=W1|<Е \JDgQCUGMd=o dGIB_xș"H@Mt!rpq!~@Zt 7)kP~0ƪ~( ЄLGYuUhk6Lԃ.hygrبJh5D JH4p/e@>mտLdDhGM$D Iܗ 1JX;㟍7', 0#8iDHkoe6T=mDm soapr |"5o~Dİѭ!Fr"l=%1،4vr2P<hѴ`D3#)?'ة㤟 sй CW0vD9L#RՉ;Kv詆 &!nc>!?!jZmŽ۞A'_a!6F?&ݻ>(Ln3 iM0P^XAB"#* LY$w+3;76'zhũss-~\4JRFB1֘!-FRtl=@u"l~( "VF+ƶBGQ =c!*RqʪzmtG9i1޿$Q! Lܴ' XETSf PXhPDqf.L]DZwK̩osN,q8Ü_"Add ^,о: O$N $/GZ/pP ;0;@ipSTzaG_5Qp(+RO5GjH;Y2eMO>8.@JSC~I+ D"Df3 uJ:TKrGsWGgߵ[Pj7Dۖ/EV^%2D.L :SD\V"iЂ;PC0)#\D}D#ϭ03W MH慀翩T rQ7p WD\?9O tTQ/'(U‘@ԵOF˦W }C\C)A$@X4"rTSP$mGQq"\?[i"Bb`(UDpPD/b@gmsv%ū$lQ /[GElWGƕZZsS#*pAd ZJXhw&킲ڌ=iD/@i"45Q+b>&*+yנQ7*- " uN@"\냨] Hz*$\8:LV.QrJ4'B}Pkג&P$V0a^O$naK=lz ƧPmf% d GQ>џPOo\)تNb%/C# 0EdQ HV]*HdX:@[c1gG*#ڤ+)0 D?@BmfK|XX+4y0"RݜRic`̑TD;q{Qy-~** -~B6(s**~ΝP~sB<(h >8;7W\&t`2bQ%Zb}"\9ui`l 1Q"PT}FAd cj]|niSM&/(iKDjDb_?Kp{)s$ }"2 [dWjȧtv$|@_6yn 1xg(UYk-\t]pb="Fn+sB9zlzm3-tLsZ؁tD/:9uQ] nr8~"es>h:-\/*XbvIhջG}01M VFy&r{F~`2^ŷذ+0j+y.tFnkdMvB{Q'[n1,Em ϶ QxCe6db9GJfs/3]B.,^|~6:xҦOQ5D~G^ys\ɢEAzlQwH55ꃸcYnlKs2'=. J?h QۜC'1T|u[-=0uS^݀S a/뫕c[t7,ai,9-Dm2ιYj6f%zenXd$pl1l#UWΉӿy L,ю~a6 gp#Bp)\hعBcfXuǟ,e:p.g `O17~1;ewU43  }=[:iOheÜ^TA1ٜ3e}@DA]*! g6Ҁ5/xһĔ<.L{w&̤Q'N.ל$w$Ӿ*ؽ 42qVvlDdbF(h{Ф^G7/=~ 1Y66^T93DbRmPE}n{ A׺900%Dlsoͱs翍d=2x;գ6{NP@!g ge\Qs9's?i>Xv'?sA QU*c g p@v9T&T'wJ1߽yqY]x{sM:Bէ9g&ZJEԢR 0" @> !o!sTSZ^ڟ~H U5pT)Q4Y @$M<[y{ݡ0жM$6X A$B;V}t 3?>@8#DfGNXCoZHŷsY7pDV-Ԭ2ݯ[!w%[pz)[RVg%Lo G[6/3Į@aB^듻rޟL2]4`{Å'2rk;>@wkT|rˇ [jB{gt[6ؚH`Wg/GPlq1d˃={stʃ>x><-bv\? =-wJ[H8K6n,ȦKq$z/lX$ .(v(ּ̧5Ql;65SvtLYV*^DvZWz}&,N"h]Ԓ xhoFr5M"R`'Jʻe~Ezoz`C8ˍSYۗGUDicx{o%IцDόF[*bDKEEMI ҿÞg,Ya.9)|3z])!䬼bj.Ԣp~>M*[JD xZL?8ZgPcDMH!㌟ Dl DJ親CgZ##mZ hA|zU_]n&W͹'Mr=^Mwkw/t1P[l EN{P+´򴘼VdhS(^=-ᔯ5rz pp[t@3+Fr`a)&횘{IP-ܚ:+۰GNyPفhǵfy V6"_8@V ,B;ژerp֭VN"j=6n{ =a-#k#V ?)ymn@v(FKg#p*ha<f]!$ט Omn "ؾ6n Pwr@ČބX AƋUBA{"}UDܿvYU)Qmxj.Mh3knDPrG/:- >@EMv`Dҷd+w*YvQkcv%?RB-@pnƕ8y&bjFAiV .ߓ7ĚS(["p ^*bO4/[0@Qu tlէ A3Jյ4֡?_z^L񲩅3 DSrgC*}@9E st%q֜X?U{UG\  X/eK b9p^R lMh;Ez "/>XxD: {Dd䭮b0ʼm F6&,jۏF z檈-[9~N3}؋X RP>D^9 ,\fAdlJjEv݃XP`&ge爅9omOH9v]:?q4;+70 `@5G4,'uU"5 jAaD@RBP>+ :qv:&{0IEktpgf:D/|*O_i';Lہ9UIjq[Hڦ ʁ šm6e:oDZ촚 ?W#ph~[R8=y _!5#aV`Q"H#j/]SA2lrw "%"2/e_Ks B4gclUh܍-gWVhCjrw "0_l"2SC;m<&Y$kqdbAv/p.֓x o2t%.u"h1@ *a2"[(;3hoޒnTЁV;V R@ܼ-˝tWY\kR}>^uҭk)C?*t ǡKI M@t㛭JݞP[Z)B @\u<@i84voX&j/suN7Q ۝77,u"U#0/ VD ^"ٚ=݂pR@NT4G6jm)!4Aډ>[T,Sr!L<`/ tS3Pa_1xkzSoy:7^U_r,"-(L kFD 2 kB'(rkyĶ{L;0D\4@Z6(CDN}P;TCϓN'-J3J @L(@Qo7m*@T2jJP"ź",d7L,緑TILP"% 3TEI 8aSyY D r:HbPZZK $O7&#, uwHMSQ4<"32L d,z\g #"`"-k5KmgRBBq1+e:Bm24=+ P:4ՠWT;YR` MxRYp#J ڄ "E{Df7H?<=}Hĭ >H Dwe.>y"XZ`Aڄ "6 B55Y: $?z))]H* :ίA_HC֢SlUmq "Mr熑D,ڦXȣHT-ERϫAM?[2F":nagDAc]v?gM@yQ,7DS͔4I"{ B?{` "z":"$=ʎ(K-@63dJڳ[e  T=o@>'5݀ɣ:K-@:v%C!DX`n\?:LڜnwDYQXئS9(0LeH<p̓h#ln=[%@䅸CΨj5/VA7K} } r"o$ey7C:>u.̨N@n2NkF @:٪=՝]1WP(*"eNEzS_%mZdޜ)T  a0#PKGh}nmr gǺqW7}iģfI˚C2N@R{2H3 Dj!6' ^$*SkH/D#6&Z Z{ ˲6 zY\>3q+Yq!Iw}-٥^B&anSwYNSVSQfڔw"%k$=<2,7D0JOzaM[Eis^&ŮY*ۼZQnٝ9o[ϔ%g-teښ[e56Ӂ#]\scQgB[a4'YRH-};MC ɢ,T2;Z Aw=uJY R(VLB Yە1o`L; HU933HD1c,jݐ l`";f <Ex?-Vֵ[By9 iu"5m G@Be§  qK#Dz/gdn+JHȩsl J9 7 m¥nS;I= O@Y#^\.p +3rjFJjdFV-r R"Et @T|tIڎHG%D4[`@^Iۚ_bȝu,ԠS{'RQТQ1HDpw @䌝ZD]FFzܕFl 24?GJ&,lVz{=Iڌ£]V/дFeDpp@ocxKL6m+/egdÄ&2yI@UȌ-S)ҁ9g4X{ _'jI<]"vASu zԢVܯF@Б89 xaL1 TxNO PY.(Oj-)̿}Wxכ٢-cZX)he@bsNT]`ARYG~p,kZBOB #o|SR~L#7F!۸_y?8x8rug^|N0lG뮨XpAl$63/Y"j۬^@ 'GR-wwK#R.j7j4 "mMpz*pX`M$j3riaRG`2ȱXs)m$$jF6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH R`R r 9Normal d CJPJ^J_HaJmH sH tH DA`D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List h$h 310Envelope Address*d&#$+D/^@ PJRR 30 Balloon Text dCJOJQJ^JaJN/N 30Balloon Text CharCJOJQJ^JaJ<!< e0Placeholder TextB*PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] @ @C @lx~s#/5nz!)9cou$*EQW )5;=MUe 8DJR^d#)lx~ $ * B N T o { FFFFFG$G$FFFFG$G$FG$G$FFFFFFG$G$FFFFFFFFFFFFFF8@0F(   b L&  #" ?H  # >LH  # >&L&h  # C"? ,\  *,U    "\   # >#" ?U *,U \   # >#" ? *, D   "`D   "`D   "`D   "`D   "` D   "` D   "`D   "`B S  ?O  &:;<= |Tt|[+t)t TZ)tD)1't,)dtu) tt")^8t_) t)t)vt$Text1Text2Text3Text4Text5Check1Check2Text6Text7Text8Text9Check3Check4Text10Text11Text12Text13Text14Text15Text16Check5Check6Text17Text18Text19Text20Text21Text22Text23Text24Text25Text26Text27Text28Text29Text30mt$o*dF*>V9Sm C p   !"#6":v+X<Nf!Ke*+ U   L )1gjL 33333:>- U V K L hc\lgo`O$r 96?*C&~F+twS3k4h731#?*q}N,Owe|L N @d  *Unknown G* Times New Roman5Symbol3. * Arial9. "[ Segoe UI7 Gautami?. Arial Black7.{ @Calibri5. *aTahomaA BCambria Math"1h;;/P  !n0F 2HX $Pgo2!xxUNAUNAf 666666666vvvvOh+'0|  8 D P\dltUNA$Accident-Injury Report Form.dotxUNA2Microsoft Office Word@ِ@:K@:KP ՜.+,0 hp  University of North AlabamaF   Title  "#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXZ[\]^_`abcdefghijklmopqrstuwxyz{|}Root Entry F0`Data !o1TableYBWordDocument .NSummaryInformation(nDocumentSummaryInformation8vMsoDataStore ` `IFJKOTKF4F==2 ` `Item  PropertiesUMacros ` `VBA ` `  !"#$%'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPRSTUVWZ ز0* pHdTemplateProjectQH@  = | [H J< 9stdole>stdoleP h%^*\G{00020430-C 0046}#2.0#0#C:\WINDOWS\system32\e2.tlb#OLE Automation0EOfficEOficEE2DF8D04C-5BFA-101B-BDE5EAAC42Egram Files\@CommonMicrosoft Shared\OFFICE12\MSO.DLL&#M 1q Ob LibraryKdir ThisDocument _VBA_PROJECT& PROJECT QMSForms>SFrms3D452EE1-E08F0A-8-02608C4D0BB4SFM20L'B &/;"1jIqAHq00}t#0Bq# 504 AE1433AAC-3358-4220-B06A-2A98E8D6466@)ÉDOCUME~1\kk`p\LOCALS\Word8 .0c7.exdd<@".E .`PM BDThisDocum@entGTi@lD@lcuQ@oen 2E HB1%B,""+#xME (SLSS<N0{00020906-0000-0000-C000-000000000046}8(%HxAttribute VB_Name = "ThisDocument" Bas0{00020P906-0C$0046} |GlobalSpacFalse dCreatablPredeclaIdTru BExposeTemplateDerivBustomizD2a  *\G{000204EF-0000-0000-C000-000000000046}#4.0#9#C:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#8.4#0#C:\Program Files\Microsoft Office\Office12\MSWORD.OLB#Microsoft Word 12.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\WINDOWS\system32\stdole2.tlb#OLE Automation(*\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.4#0#C:\Program Files\Common Files\Microsoft Shared\OFFICE12\MSO.DLL#Microsoft Office 12.0 Object Library*\G{0D452EE1-E08F-101A-852E-02608C4D0BB4}#2.0#0#C:\WINDOWS\system32\FM20.DLL#Microsoft Forms 2.0 Object Library*\G{E1433AAC-3358-4220-B06A-2A98E8D64660}#2.0#0#C:\DOCUME~1\kkharp\LOCALS~1\Temp\Word8.0\MSForms.exd#Microsoft Forms 2.0 Object Library.E .`M  [HThisDocument03485b9397ThisDocument% a ԉ{=Ik` %WordkVBAWin16~Win32MacVBA6#Project1 stdole`TemplateProjectE ThisDocument< _EvaluateOfficeuMSFormsC CheckBox1T ID="{C5A086EF-EE04-4594-B9F2-E3E731CAD21E}" Document=ThisDocument/&H00000000 Name="TemplateProject" HelpContextID="0" VersionCompatible32="393222000" CMG="C0C2CDCBD1CBD1CBD1CBD1" DPB="71737C817D817D81" GC="22202F9CE19DE19D1E" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 &H00000002={000209F2-0000-0000-C000-000000000046};Word8.0;&H00000000 PROJECTwmX)CompObjYyThisDocumentThisDocument  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89qy JLbjbjEE .N''))<<<<<<<<<lD= <=P=P=P=P=P=P=P=P========?B=<P=P=P=P=P==<<P=P==P=P=P=P=<P=<P==P=P==P=P=<P=P=6`<P=P=l==0=P=BP=BP=B<P=P=P=P=P=P=P=P=P===P=P=P=P==P=P=P=P=BP=P=P=P=P=P=P=P=P=m/ v;:  ,1h/ =!"#$% vvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~OJQJ_HmH nH sH tH Z`Z Normal d(CJ OJPJQJ^J_HaJ mH sH tH DA`D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List <`< 50Placeholder TextB*PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] N< R ` "0|2*J.16L L 5@Unknown G* Times New Roman5Symbol3. * Arial9. "[ Segoe UI7 Gautami?. Arial Black7.{ @Calibri5. *aTahomaA BCambria Math"0h0@P $P52!xx