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INCIDENT, NEAR MISS AND LOSS <br /> REPORT <br /> �. (HSE 1 AUTO 1 PROPERTY) <br /> Stantec <br /> SECTION 1 - GENERAL <br /> La <br /> STANTEC EMPLOYEE(S)INVOLVED <br /> Name Address Phone No. <br /> v <br /> l <br /> OTHER PERSONS INVOLVED(Including Stantee Sub-Contractors/Consultants) <br /> Name Address hone Employer(if applicable) <br /> i.. <br /> DESCRIPTION OF THE INCIDENT <br /> Describe the incident and provide as much detail as possible with respect to what happened and how it happened.For lost,stolen or damaged equipment <br /> rovide a list includin the value and serial number of each piece of a u! mens. Attach additional sheets If required. <br /> v <br /> Type of Contact(see Table 1): <br /> WORK SITE CONDITIONS AT TIME OF INCIDENT(Describe weather, housekeeping, etc.) <br /> WITNESS INFORMATION <br /> Name Name <br /> i" Address <br /> Address <br /> Phone Phone <br /> Employer Employer <br /> V <br /> POLICE <br /> Was a Police Report filed? ❑yes ❑ No File No. City: <br /> Name of Officer Badge No. <br /> Charges Laid ❑Yes ❑No Person Charged Type of Charge <br /> IMMEDIATE ACTIONS TAKEN(Must be completed for All Incidents) <br /> �.. What immediate actions were taken to prevent further injury or damages? <br /> IMMEDIATE CAUSES: Substandard actions and or conditions that caused or could cause this event, See Table 2 <br /> V <br /> i.r <br /> UNDERLYING CAUSES: Specific personal or job factors that caused or could cause this event, See Table 3 <br /> HSE-620 Incident, Near Miss&Loss Report Rev. 10-08 Page 2 of 6 <br /> LN <br />