This government document is issued by Labor, Department for use in North Carolina
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https://www.google.com/url?client=internal-element-cse&cx=d6d0fe261fe46d105&q=https://www.labor.nc.gov/osh/osh-example-programs/accident-and-injury-reports/open&sa=U&ved=2ahUKEwi8z7fHqI-GAxU0RPEDHTJZBSk4PBAWegQIBxAB&usg=AOvVaw024wPPxmvsJ3ECfscwu7lD&arm=e&fexp=72519171,72519168