LSJE, LLC

LSJE, LLC 6100 Red Hook Quarters, Suite B-3, St. Thomas, VI 00802-1348 Phone: E-mail: Accident Report Form Today's Date: 12/12/18 Date of Incident: 10/05/18 Employee Name: Title/Position: Kyle Steward 'Landscaping Location of Incident Witnesses: the Job (LSJ) 'Gael (work) Was employee wearing recommended safety devices and exercising proper operation procedures? ID Yes El No Comments: Helping Gael start weed eater when started. Moving fumiture out of F450, pulled shoulder. Felt also during plumbing. Muscle pulled in shoulder. [By phone - SR 12113/181 Employee (select one): Doctor and/or Hospital Visited: Date(s) of Visit: El Accepted Medical Treatment E Declined Medical Treatment Red Hook Family 10/05/18 Date(s) of Follow-up Medical Treatment (if applicable): Has employee provided a doctor's written permission to return to work? If no, when is employee able to return to work? Employee Signature: Supervisor Signature: El Yes El No Employee is already back to work Date: Date: EFTA01223279