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31290 N. US Highway 45 unit "B" Libertyville, IL 60048
Phone: 847-680-1504 Fax: 847-680-0122
Hours: Mon through Fri 7:00am to 4:00pm
Injury/Illness Report
Date of Injury/Illness:
Specific Activity:


Description of Incident:
Injury Type:
Body Part (Check all that apply):
Source:
Event:
Extent of Injury:
Was the appropriate safety equipment provided?
Was it in use?
How could this injury/illness/incident have been prevented?
Reporting Company:


 

31290 N. US Highway 45 unit "B" Libertyville, IL 60048
Phone: 847-680-1504 Fax: 847-680-0122
Hours: Mon through Fri 7:00am to 4:00pm

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