Laserfiche WebLink
GROUNDWATER TECHNOLOGYo INC <br /> Acci4ent/Ine3dent/Near Miss Report <br /> ~Employee's Name: D.O.B. <br /> Address: D.D.H. <br /> SSS <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) __ 2) <br /> Conditions/acts contributing to this incident: <br /> Explain specifically the corrective action you have taken to prevent a <br /> recurrence: <br /> Dist 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 /> 'late Date Date ~� <br /> -Phis form must be completed and returned within 5 working days to Regional Health & Safety Manager, who will forward a copy to <br /> Corporate Health & safety Manager at ELa. <br />