EFTA01223279.pdf

LSJE, LLC 6100 Red Hook Quarters, Suite B-3, St. Thomas, VI 00802-1348 Phone: E-mail: Accident Report Form Today's Date: 12/12/18 Date of Incident: 10/05/18 Kyle Steward 'Landscaping Employee Name: Title/Position: the Job (LSJ) Location of Incident 'Gael (work) Witnesses: Was employee wearing recommended safety devices and exercising proper operation procedures? ID Yes El No Helping Gael start weed eater when started. Moving fumiture out of F450, pulled shoulder. Felt also during plumbing. Muscle pulled in shoulder. [By phone - SR 12113/181 Comments: Employee (select one): El Accepted Medical Treatment E Declined Medical Treatment Red Hook Family Doctor and/or Hospital Visited: Date(s) of Visit: 10/05/18 Date(s) of Follow-up Medical Treatment (if applicable): Has employee provided a doctor's written permission to return to work? El Yes El No If no, when is employee able to return to work? Employee is already back to work Employee Signature: Date: Supervisor Signature: Date: EFTA01223279