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INCIDENT, NEAR MISS AND LOSS REPORT 0, - (HSE 1 AUTO 1 PROPERTY) StantK Office&PC No.: Date of incident: Project: Time of Incident: Location of Project: Project No.: Location of Incident: Client: ~ Person in Charge: Reported to: Reported By: Time Reported: -� Date reported: Time employee started work: ❑ am ❑ pm Type of Incident ®Auto ❑ Property Loss ❑ Environmental ❑ Occupational Illness ❑ injury ❑ Medical Aid ❑ First Aid ❑ Non-First Aid ❑ Near Miss Print Name&Title Signature Date COMPLETED BY Print Name(Project Manager) Signature(Project Manager) Date REVIEWED BY Print Name(PCML) Signature(PCML) Date Print Name(OSEC) Signature(OSEC) Date This document contains privileged and confidential information prepared at the request of Stantec's Legal Counsel.The contents of this report are restricted to HR personnel, Risk Management Representatives, Project Manager and PC Leader,and Stantec's Insurer, Adjuster and Legal Counsel. Information collected will be used solely for the purpose of meeting the requirements of Stantec's HSE and insurance programs, complying with applicable legislation, and will be used in accordance with any governing privacy legislation.The information collected will be maintained on file and may be included in required reports. INSTRUCTIONS: This form must be completed and submitted with in 24 hours of any incident, near miss or loss. Where possible the Worker or Workers involved shall complete this form, alternatively the Project Manager, OSEC, or other employee may complete and submit this form. Do not delay submission waiting for signatures. Fax unsigned Report immediately to(780)969-2030 and forward original once all signatures have been obtained. Project Managers will follow up on all verbal incident reports to make sure written reports are submitted. Complete Section 1 for ALL incidents. Complete Section 2 for any incident involving injuries, illnesses and environmental incidents or where an injury, illness or environmental incident could have occurred. Complete Section 3 for any incident involving a vehicle owned, leased or rented by Stantec. Attach copies of Police Report, Repair and/or replacement estimates, documentation of original costtpurchase for property/equipment losses, if being replaced. Attach Diagram of Scene or Photographs if required. (use diagram on page 5 for auto accidents) Return original completed and signed form to Stantec's Practice and Risk Management group(Edmonton)with a copy to regional Human Resources(only if medical aid required). Any supporting electronic documents can be sent to riskmgt(a)stantec.com. HSE-620 incident,Near Miss&Loss Report Rev. 10-08 Page 1 of 6