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OTIE- <br /> pwATMN 111"'Ild 11119 1 <br /> ACCIDENT INVESTIGATION REPORT <br /> Page 1 of 3 <br /> This report is to be completed following the injury or illness of OTIE personnel. Answer <br /> all questions as completely as possible. Forward this report to the CORPORATE SHM <br /> within 24 hours of the accident. See instructions for directions to complete this form. <br /> IDENTIFICATION <br /> Date and Time of Accident: Date Reported: <br /> Employee Involved: Position: Date Employed: <br /> Experience on the Job: <br /> Location: <br /> Name of Project/Project No.: <br /> Supervisor: Witnesses: <br /> INCIDENT <br /> Accident Resulted in: Recordability: Nature of Injury: Type of <br /> ❑ Injury ❑ First Aid Accident: <br /> ❑ Illness ❑ Medical <br /> ❑ Property Damage ❑ Lost Part of Body: <br /> Time <br /> Description of Accident: <br /> ANALYSIS <br /> Describe Hazards, Unsafe Condition(s)or Acts: <br /> Describe Underlying Cause(s) or Failures: <br /> CONTROLS <br /> Recommended Corrective Action: <br /> Action Taken: <br /> FOLLOW UP: Scheduled: Conducted By: <br /> Investigated by: Print Name Si nature Date <br /> Employee <br /> Supervisor <br /> Reviewed by: Print Name Signature Date <br /> SHM <br />