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GROUNDWATER TECHNOLOGY# INC. <br /> Accident/Incident/Near Miss Report <br /> Employee's Name: D.O.B. <br /> Wdress D.O.H. <br /> SS# <br /> Job Title: Supervisors's Name: <br /> Office Location: <br /> Location at Time of Incident: <br /> Date/Time of Incident: <br /> Description: Describe clearly how the accident occurred: <br /> Was Incident: Physical Chemical <br /> Part(s) of body affected: Exposure: Dermal <br /> right left Inhalation <br /> Ingestion <br /> Witnesses: 1) Z) <br /> 4konditions/acts contributing to this incident: <br /> Explain specifically the corrective action you have taken to prevent a <br /> recurrence: <br /> Did the injured go to a doctor? Where? <br /> When? <br /> Did injured go to a hospital? Where? <br /> When? <br /> Signatures: <br /> Employee Reporting Manager Regional H&S Manager <br /> .Date Date Date <br /> This form must be completed and returned within 5 working days to Regional Health 8 Safety manager, who will forward a copy to <br /> Corporate Health 8 Safety Manager at ELO. <br /> 117F147—'GROUNDWATER <br /> TECHNOLOGY, INC <br />