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APPENDIX A-4: ACCIDENT/INCIDENT REPORT FORM <br /> Employee Injury/Exposure Incident Report <br /> This section for use by Corporate Health and Safety Officer(CHSO) <br /> OSHA Reportable 9 Yes ( ) No ( ) Reason? <br /> This report must be completed within 24 hours of the incident and forwarded to the AES-RS CHSO <br /> Name <br /> Social Security Number <br /> Branch Office <br /> Date of report <br /> Project#/Site Name Task/Phase <br /> Incident type possible exposure ( } exposure (} injury ( ) <br /> Date of Incident Tim-- <br /> Location <br /> Site Conditions at Time of Incident <br /> Temperature Wmd Speed &Direction Humidity <br /> Cloud Cover Precipitation <br /> Other <br /> Material exposed to (chemical name, physical state, etc ) <br />