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r <br />a. <br />Project # <br />Project <br />Date: <br />C <br />Was weather a factor? <br />Unsafe mechanical/physical/environment condition at time of incident (be specific) <br />Unsafe act by injured and/or others contributing to the incident (be specific, must be answered) <br />Personal factors (improper attitude, lack of knowledge or skill, slow reaction, fatigue) <br />ON -STYE INCIDENTS <br />of personal protection equipment required in Site Safety Plan <br />Modifications <br />Was injured using required equipment? <br />ROUX ASSOCIATES INC atasaoa <br />