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INCIDENT REPORT <br /> (This form is to be completed for all Kennedy/Jenks' employee(s), subcontractor, <br /> vendor, client, and visitor incidents) <br /> INSTRUCTIONS: All geld related Incidents(employee,subcontractor,vendor,visitor,etc)require all applicable sections <br /> of the Incident Report to be completed by the Site Safety Officer(SSO)or Field Site Safety Officer(FSSO). If unable to <br /> do so,the Project Manager or designee supervising the geld work Is to complete the Incident Report. <br /> Project Number: <br /> Name and title of person <br /> completing this form: <br /> Nature of incident: Accident/Injury <br /> Illness <br /> Property Damage <br /> Spill or Release <br /> Other <br /> Field Information <br /> Date of Incident: Time of Incident: <br /> Location of Incident: <br /> Site conditions(weather, physical): <br /> Task performed when incident occurred: <br /> Incident due to equipment failure, human error, etc.: <br /> 4 <br /> rt+rwmwnrnasr,gsvmre�+w.Haman o wsrupam®o.ameaamor< <br />