Laserfiche WebLink
! Y <br /> ATTACHMENT 4 <br /> SECOR INJURYALLNESS REPORT <br /> DATE OF INCIDENT CASE NO 'TIME OF DAY <br /> EMPLOYEE NAME DATE OF BIR <br /> HOME ADDRESS PHONE NO <br /> SEX MALE_ FEMALE— AGE_ JOB TITLE SOCIAL SECURITY NO <br /> OFFICE LOCATION DATE OF HIRE <br /> WHERE DID INCIDENT OCCUR?(INCLUDE ADDRESS <br /> ON EMPLOYER'S PREMISES? YES - NO_ PROJECT NAMEINO <br /> WHAT WAS EMPLOYEE DOING WHEN INCIDENT OCCURRED?(BE SPECIFIC) – <br /> HOW DID THE INCIDENT OCCUR?(DESCRIBE FULLY) <br /> WHAT STEPS COULD BE TAKEN TO PREVENT SUCH AN INCIDENT? <br /> I <br /> OBJECT OR SUBSTANCE THAT DIRECTLY CAUSED INCIDENT? <br /> DESCRIBE THE INJURY OR ILLNESS PART OF BODY AFFECTED <br /> NAME AND ADDRESS OF PHYSICIAN <br /> IF HOSPITALIZED,NAME AND ADDRESS OF HOSPITAL <br /> LOSS OF ONE OR MORE DAYS OF WORK?YES/N0_ IF YES-DATE LAST WORKED <br /> HAS EMPLOYEE RETURNED TO WORKS YESINO_ IF YES-DATE RETURNED <br /> DID EMPLOYEE DIE?YES/NO IF YES DAT <br /> COMPLETED BY(PRINT) EMPLOYEE SIGNATURE <br /> (Supervisor or Site Health&Safety Officer) <br /> DATE <br /> SIGNATURE <br /> PIC SIGNATURE <br /> DATE <br /> DATE <br /> 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 <br /> reviewed and signed by the Principal-in-charge and transmitted to Corporate Health and Safety,and Health&Safety Coordinator within 24 hours of the incident,even if <br /> employee is not available to review and sign Employee or employee's doctor must submit a copy of the doctor's report to Corporate Health and Safety within 24 hours <br /> of the initial exam and any subsequent exams For field injuries,submit a copy of the Health and Safety Plan A detailed synopsis of events including corrective action to <br /> be taken must be submitted by the PIC to Corporate Health&Safety within I week of the injury/illness REV 11 <br />