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ACCIDENT REPORT S TAT E U N I V E R S I T Y O F N E W Y O R K Human Resources Haggerty 203 845 257-3171 Fax 845 257-3621 Name Last First Middle Initial Address X X X X X Social Security Number Date of birth Phone numbers s Sex Male Female Job title Regular passdays Regular work shift Finish AM PM Dept. Assigned AM PM Supervisor Start AM PM Time that employee began work on date of accident WORK-RELATED ACCIDENT/INJURY INFORMATION Date of accident Time of accident AM PM Specific location of...
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