WORK PLANS - Laserfiche WebLink

Home Browse Search

• Attachment 3 • IncidentInvestigation/ Near-Miss1Report INCIDENT TYPEDate of Incident; ❑ Fatality ❑ Industrial Non-Recordable ❑ SpilULeak ❑ General Liability ❑ Lost Workday ❑ Non-Industrial ❑ Product Integrity ❑ Criminal Activity ❑ LW Restricted Duty ❑ Off-the-Job Injury ❑ Bquipment ❑ Notice of Violation ❑ OSHA Medical or Illness w/o LW ❑ MVA ❑ Business Interruption ❑ Near Miss ❑ First Aid ❑ Fire (TO BE COMPLETED BY HR) This report must be completed by the employee's supervisor or Site Health and Safety Officer immediately upon learning of the incident. The completed report must be reviewed and signed by the Principal-In-Charge and e-mailed or faxed to the Vice President of Human Resources, Corporate Health and Safety and the Health&Safety Coordinator within 24 hours of the incident,even if employee is not available to review and sign. Employee or employee's doctor must submit a copy of the doctor's report to Human Resources within 24 hours of the initial exam and any subsequent exams. Phone: 619-718-9429,Fax:619-296-2006,E-Mail:mharris@secocconL Company Name: Work Location Address where incident occurred: Project Name: Name: SSN: Birthdate: Employment Status: ❑ Full-Time ❑ Part-Time ❑ Hourly-As-Needed How long in present job? INJURY OR ILLNESS INFO Where did incident/near miss occur? (number,street,city,state,rip): County: On Employer's premises? ❑ Yes ❑ No Specific activity the employee was engaged in when the incident/near miss occurred: All equipment materials,or chemicals the employee was using when the incident/near miss occurred(e.g.,the machine employee struck against or which struck employee;the vapor inhaled or material swallowed;what the employee was lifting,pulling,etc.): Describe the specific injury or illness(e.g.,cut,strain,fiacmM skin rash,etc.): Body parl(s)affected(e.g.,back,left wrist,right eye,etc.): Name and address of Health Care Provider(e.g.,physician or clinic): Phone No.: If hospitalized,name and address of hospital: Phone No.: Date of injury a onset of illums(MM/DD(YYYY) / / T➢me of event or exposure: ❑ AM ❑ PM Thme employee began work: ❑ AM ❑ PM Did employs lose at least one full shift's work? ❑ No ❑ Yes,Ist date absent(MM/DD/YYYY) Has employee retumedlowork? ❑Regular work ❑ Restricted work ❑ No,still off work ❑ Yes,date retained(MM/DD/YYYI') Did employee die? ❑ No ❑ Yes,date(MM/DDKYYY) Date employer notified of incident/near miss: (MM/DD/YYYY) To whom reported: __.. Other workers injured/made ill in this event? ❑ Yes ❑ No SECOR International Incorporated 26 HASP 061702.doc