Supervisors Report Of Mishap
Company/Location
OHK Goshen
Western Milling Goshen
OHK AZ
Western Milling AZ
Western Milling Fomosa
Name of employee
Date of Injury
/
/
Time of Injury
01
02
03
04
05
06
07
08
09
10
11
12
:
AM
PM
Division
Mill
Sack
Admin
Transportation
Management
Occupation
Did the employee receive treatment by a physician:
Yes
No
Description of Injury
Name of person submitting
Phone Number
(
)
-