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The Righteous Inn – Accident and Incident ReportFormAccident and Incident Report FormInjured/ill worker’s detailsFirst name:EmmaLast name:RogersPosition:Room attendantDepartmentHousekeepingWorkers AddressUnit 65/240 Bondi Road, Bondi NSW 2026Manager/supervisor’s name:Bruna StrebInjury or illness detailsDate ofinjury/illness:04/05/2020Time ofinjury/illness:10.30amam/pmNature of injury/illness:Back pain due overreaching high level areas to be cleanedBodily location of injury/illness (for illnesses include symptoms):Lower backLocation at time of injury:Room 204 /level 2- BathroomHow was the injury/illness sustained (cause of injury /illness):
She didn’t use an extension pole to reach high areas while cleaningWas any plant, equipment, substance or thing involved in the injury/ illness? If yes, please providedetails:NOWitnesses:Were there any witnesses to the injury/illness? Yes or No. If yes, please list name andcontact number for each witness:NoName:Contact:Name:Contact:Name:Contact:Name:Contact:Name:Contact:Follow upHas the injury been reported to the worker’ssupervisor? Yes or No:Was any treatment provided? Yes or No. If yes, please provide details:

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Term
Three
Professor
N/A
Tags
Occupational safety and health, Injury, Physical trauma, Bruna Streb

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