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Vi YI Attachment 4 Jncident R I i sea ss nves Z t Date of Incident INCIDENT TYPE, ❑ Fatality ❑ Industrial Non-Recordable ❑ SprlltLeak ❑ General Liability ❑ Lost Workday ❑ Non-Industrial ❑ Product Integrity ❑ Cnrmnal Activity ❑ LW Restricted Duty ❑ Off-the-Job Injury ❑ Equipment ❑ Notice of Violation ❑ OSHA Medical or Illness w/o LW ❑ MVA ❑ Business Interruption ❑ Near Miss ❑ First Aid ❑ Fire (TO BE COMPLETED BY HR) This report must be completed by the employee's supervisor or Site Health and Safety Officer immediately upon learning of the incident The completed report must be reviewed and signed by the Principal-In-Charge and e-mailed or faxed to the Vice President of Human Resources, Corporate Health and Safety and the Health& Safety Coordinator within 24 hours of the incident,even if employee is not available to review and sign Employee or employee's doctor must submit a copy of the doctor's report to Human Resources within 24 hours of the initial exam and any subsequent exams Phone 619-718-9429, Fax 619-296-2006, E-Mail mharris @ secor com After hours or weekends, please call Marguerite Shuffleton Cell 619-925-8365 or Home 760-749-9603 EMPLOYER Company Name _— _-- Work Location Address where incident occurred Project Name Name - SSN Birthdate -_-_- mployment Status-❑ Full-TimeW❑ Part-Time ElHourly-As-Needed9 How long in present job9 INJURY Where did incident 1 near muss occur9 (number,street city,state zip) County On Employer's premises9 ❑ Yes ❑ No Specific activity the employee was engaged in when the incident 1 near miss occurred All equipment materials,or chemicals the employee was using when the incident/near miss occurred(e g,the machine employee struck against or which struck employee,the vapor inhaled or material swallowed what the employee was lifting pulling,etc) Describe the specific injury or illness(e g cut strain fracture,skin rash,etc} Body part(s)affected(e g back,left wrist,right eye,etc) Name and address of Health Care Provider(e g,physician or clinic) Phone No If hospitalized name and address of hospital I Phone No Date of injury or onset of illness(MMIDDIYYYY) 1 I - - 1 Time of event or exposure - - ❑ AM- ❑- PM Time employee began work El AM [I PM Did employee lose at least one full shift s work ( ❑ No ❑ Yes, 1 st date absent(MM/DD/YYYY) 1 I Has employee returned to workv-❑Regular work -❑ Restricted work -❑ No,still off work ❑-Yes date returned(MM/DD/YYYY) -- Did employee due9 ❑ No ❑ Yes date(MMIDDIYYYY) 1 I ate employer notified of incident I near miss (MM/DD/YYYY) ! 1 To whom reported Other workers injured/made ill in this event? ❑ Yes ❑ No SECOR International Incorporated 22 Generic HASP 6-14-01