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Environmental Health & Safety |
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Employee's
Last Name:
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Employee's
First Name:
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CSUN ID Number: |
| Position Title: | Department: | Telephone: |
| Supervisor's Name: | Accident Location: |
| II. Provide a description of exposed employee's duties as they relate to the exposure incident: | |
| (Attach additional information, if necessary) | |
| II. How did the accident occur? Please provide an explanation of the route(s) of exposure and the circumstances under which the exposure incident occurred: | |
| (Attach additional information, if necessary) | |
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| Employee Signature:________________________ | Date: ____________ |