Appendix B

APPENDIX B

Morrisville Public Library

83 East Main Street

Morrisville NY

Date__________________________                      Time__________________________

Place of Incident__________________________________________________________

Name of person(s) involved in incident________________________________________

Was this a person  Staff______  Volunteer______  Patron______  Other______

Name and Title of supervisor at the time of incident______________________________

Name(s) of witness________________________________________________________

Description of incident_____________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Was incident a result of illness_________ or accident_________?

Was medical treatment received? _________________________

The above description is an accurate representation of the occurrence of imjury.

Signatures:

Injured Party______________________________________  Date__________________

Witness(es)________________________________________ Date__________________

Supervisor_________________________________________ Date__________________

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