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INCIDENT, NEAR MISS AND LOSS REPORT <br /> 0 (HSE 1 AUTO I PROPERTY) <br /> Stantec <br /> CORRECTIVE ACTIONS REQUIRED <br /> Corrective Action Person Responsible Due Date Date Completed <br /> 1 <br /> 2 �. <br /> 3 <br /> 4 <br /> INVESTIGATION COMPLETED BY <br /> Name Address Phone No. <br /> RESULTS OF CORRECTIVE ACTIONS(Verify and Validate corrective actions after implementation) ti <br /> SECTION 2: HSE <br /> INJURY/ILLNESS <br /> Name Address Employer <br /> INJURY 1 ILLNESS: Describe the specific injury or illness(e.g.fracture left arm,skin rash upper body, sprain lower back) <br /> First Aid Required If yes, by whom and qualifications <br /> ❑Yes ❑No y <br /> What First Aid was provided: (attach first aid report) <br /> Medical Aid Required If yes, name of facility and city <br /> ❑Yes ❑ No r <br /> Workers'Compensation Report Completed (or equivalent) ❑Yes ❑ No <br /> Note: Should any of the above information change,the employee is responsible for notifying HR or P&RM. <br /> SPILLSIRELEASES OR CONTACT WITH CONTAMINANTS AND HAZARDOUS MATERIALS <br /> What substance or mix of substances was involved? -- <br /> How much of the substance or mix was involved(by volume or weight)? <br /> Was the Employee exposed to the Describe exposure type(Inhalation, ingestion, skin contact) ✓ <br /> substance? <br /> ❑Yes ❑ No <br /> Offsite lmacts Observed Or Anticipated? Identify regulatory authorities that the spill or release was reported to <br /> ElYes No <br /> HSE-620 Incident,Near Miss&Loss Report Rev. 10-08 Page 3 of 6 <br />