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i <br /> t <br /> APPENDIX A-4: ACCIDENTIINCIDENT REPORT FORM <br /> Employee Injury/Exposure Incident Report <br /> This section for use by Corporate Health and Safety Officer: <br /> OSHA Reportable? Yes ( ) No' ( )Reason? <br /> This report must be completed within 24 hours of the.incident and forwarded to the AES Corporate Health and Safety <br /> Officer. <br /> Name Social Security <br /> Number <br /> Branch Office <br /> Date of report <br /> Project #/Site Name <br /> Task/Phase Incident type: possible exposure{) exposure(} injury () <br /> Date of Incident Time Location. <br /> Site Conditions at Time of <br /> f <br /> Incident: <br />` Temperature Wind Speed&Direction Humidity— <br /> Cloud Cover Precipitation <br /> Other Material exposed to (chemical name, <br /> physical state, etc.): <br /> Nature of exposure/injury (parts of <br /> body exposed/injured): <br /> Describe how the exposure/injury <br /> occurred (attach an additional sheet as necessary): <br /> Medical Care Received (Also list any medications prescribed): <br /> When? Where? <br /> By Whom? <br />