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(Check One X) ______Utilityhand ______ Night Cook ______ Steward / Relief ______ Warehouse ______ Driver_______

1. NAME (L,F,M): 2. SSN# - -

3. ADDRESS: 4. CITY/ST/ZIP:

5. PHONE: ( ) 6. DATE OF BIRTH: / / 7. AGE:

8. DATE OF HIRE: / / 9. DATE OF INJURY: / / 10. TIME:

11. SHIFT BEGAN (Time): 12. NO. DAYS ON JOB (Since last crew change)

13. DATE ON BOARD SUPERVISOR KNEW OF INCIDENT:

14. OPERATION (Name/No.): FIELD: BLOCK NO.:

15. WHERE DID INCIDENT OCCUR (Galley, Quarters, etc.) ___________________________

16. DESCRIBE (What? How? Equip/Object involved? Other factors? Use back of page if necessary)

17. NATURE OF INJURY (Cut hand, etc.) 18. DID INJURY CAUSE DEATH?

19. LOST TIME BEYOND SHIFT? 20. DID EMPLOYEE STOP WORK IMMED?

21. INCIDENT OCCUR ON SONOCO PREMISES? 22. DATE EMP. RETURNED TO WORK: / /

23. DATE SONOCO OFFICE NOTIFIED: / / TIME: 24. WHO?

25. WITNESSES (Name, address, phone#, use back if necessary):

26. CORRECT EQUIPMENT WORN/USED? WHY NOT?

27. CORRECTIVE ACTION TAKEN:

28. WHO/WHEN WAS ACTION TAKEN?

29. DATE OF REPORT: / / 30. NAME: POSITION: