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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WARNING: There are products on this website which can expose you to chemicals known to the State of California to cause cancer and birth defects or other reproductive harm. For more information go to www.p65warnings.ca.gov.
WARNING: There are products on this website which can expose you to chemicals known to the State of California to cause cancer and birth defects or other reproductive harm. For more information go to 