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General Field Work Rules and Safety Regulations <br />' Hydro-Environmental Technologies,Inc <br /> Employee Injury/Exposure )incident Report <br /> Name SSN <br /> Site Name/Client <br /> ' Date of Report Task/Phase <br /> Incident Type [ ] Possible Excessive Exposure [ } Excessive Exposure [ ] Injury <br /> Date of Incident Time of Incident <br /> Site Conditions at the Time of the Incident <br /> Temperature Relative Humidity Precipitation <br /> Cloud Cover% Wind Speed & Direction <br /> ' Other Factors That May Have Impacted the Site <br /> Nature of Exposure/Injury <br /> ' Material Exposed To Concentration <br /> Matrix Physical State <br /> Part(s) of Body Exposed or Injured <br /> i <br /> Type or Extent of Injury or Exposure <br /> Medical Care Received <br /> When Where <br /> Name of Physician <br /> ' Result of Exposure/Injury <br /> [] Death [ ] Permanent Disability [ ] Temporary Disability [J Loss of Work Time <br /> ' [ } Other Explain <br /> Was Operation Conducted According to an Approved Health and Safety Plan <br /> ' [ ] yes [] no Explain <br /> Who Witnessed the Injury/Incident <br /> ' Was the Injury/Incident due to the Failure of Protective Equipment [ ] yes [ ] no <br /> Possible Cause of Injury/Incident <br /> Possible Prevention of the Injury/Incident <br /> Signature of Person Completing Report <br /> ' Name of Person Completing Report <br /> Page 18 of 27 <br />