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AGREEMENT NUMBERAGREEMENT SUMMARYAMENDMENT NUMBER STO 215 (Rev 0612011)o# 11CA01701 A1CHECK HERE IF ADDITIONAL PAGES ARE ATTACHED 1. CONTRACTOR\'S NAMEFEDERAL 1.0. NUMBERCOUNTY OF MENDOCINO 3. AGENCY
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To fill out the STO 215 rev 0612011 form, follow these steps:
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Start by entering your personal information, such as your full name, address, and contact details, in the appropriate fields at the top of the form.
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Next, provide the name and address of your current employer or agency in the designated section.
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Fill in the details of the incident or accident being reported, including the date, time, and location.
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Describe the incident or accident in detail, including any contributing factors or causes.
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Indicate whether any injuries were sustained and provide a comprehensive account of the injuries if applicable.
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If there were any witnesses to the incident, provide their names and contact information.
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Attach any supporting documents or evidence related to the incident, such as photographs or medical reports.
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Submit the filled-out STO 215 rev 0612011 form to the appropriate authority or organization as instructed.

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