Laserfiche WebLink
rLU(dk UiAhitL GA iVG <br /> OREtiAFtY tfiClgE=KT REPORT • <br /> .r -' aeele..e <br /> Parson Cr <br /> Ynpletxrg Report bate incident Date <br /> .z Ciw i <br /> Inc,dedl Tune Location Horne DepL#—---- V izthng DepL#————— err..r <br /> arson involved In Incident Tefaphone C W"111---=--.-�----- s <br /> rnrer Name(If motor vehicle accident) Telephone ---� <br /> Type of incident: <br /> 0 Personal Injury/illness 0 Near MU Event ❑ Other <br /> 0 Chemical Exposure 0 Unsafe CondibordAction 0 Motor Vehicie Accident <br /> 0 Equipment Damage 0 FirWExplosron Assoc Leasing Vehicle# -------- <br /> D Theft 0 SpitVRel'ease VIN# <br /> 0 Property Damage D Customer Incident If FDGTI vehicle call Associates Leasing at 800�255-2607 <br /> ❑Permit/Code Compliance D Newspaper/Radlol-V Circle one based on initial findings PreventabWNon-preventable <br /> Personal Injury D Yes D No (If no,go to next section) <br /> ❑First Aid Only Person Injured <br /> ©Hospitalization 0 FDGTI Employee (If FDGTI employee complete First Report of Injury) <br />' ❑Medical Treatment ❑Subcontractor <br /> D Possible Injury,Not Confirmed 0 CustomarJPubiicJOttier <br /> Nature of Injury Illness or Exposure <br /> 1P,cnbe nature of Incident,how It oacud-ed who was Involved witnesses and possible causal factors <br />' 0 First Report of Injury Attached ❑ Police Report Attached <br />' Describe Immediate actions taken and persons notified w - ...e --y) <br /> Line Manager(Responsible for Follow-up) ot5ce <br /> DISTRIBUTION <br /> Provide this report to the line manager irnmedialey The fine manager is responsible for ffie proper drstnbubon of the PIR form per the tnadent <br /> Repcnng Guide(see reverse side) Notrfy Corporate of at Class 11 and Ill Irladents rrrxnedcatety by phone at(800)1376-0647 Madbox'11911 and tax <br /> a copy of the PIR to Norwood at(61 T) 769-9861 <br /> Rev 4196 <br />