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County of Wayne Human Resources


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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By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.
Signature HereKASEY LACH Will Sign Here
03/25/2023Click to Sign
Signature HereClick to Sign

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