Date of Incident 12A. Date Employer was notified 12B. Reason for not reporting incident(s) 13. Information about other events that occurred before incident(s) 13A. Injuries and/or other injuries suffered on same date as the event(s) 13B.
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SUPPLEMENTARY REPORT ON ACCIDENTS AND INDUSTRIAL DISEASES SUBMIT THE WKC-12 WITH THIS REPORT IF IT WAS NOT PREVIOUSLY SUBMITTED. Provision of your Social Security Number (SSN) is voluntary. Failure
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