The purpose of this form is to document events and circumstances surrounding

accidents or incidents with no injuries OR when an employee chooses not to go

to the doctor. Filling out this form does not waive the employee's right to a

future Workers' Compensation claim for the same injury. This form is for

documentation purposes only.

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Signature HereMichael Dawson Will Sign Here

04/16/2024Click to Sign

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County of Wayne Human Resources

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Michael Dawson