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APPENDIX A-4: ACCIDENT/INCIDENT (NEAR MISS) REPORT FORM <br /> Employee's Name: D.O.B. <br /> Address: D.O.H. <br /> SS# <br /> Job Title: Supervisor's Name: <br /> Office Location: <br /> Location at Time of Incident: <br /> Date/Time of Incident: <br /> Project Name: <br /> Project Number: Project Mgr. <br /> Describe clearly how the accident occurred: <br /> Was incident: Physical Chemical <br /> Parts of body affected Exposure: Dermal <br /> right left Inhalation <br /> Ingestion <br /> Witnesses: 1) 2) <br /> Conditions/acts contributing to this incident <br /> Managers must complete this section: <br /> Explain specifically the corrective action you have taken to prevent a recurrence: <br /> Did injured go to doctor: Where: <br /> When: <br /> Did injured go to hospital: Where: <br /> When: <br /> Signatures: <br /> Employee Reporting Manager Health & Safety Representative <br /> Date Date Date <br /> Accidents must be reported immediately; this form must be completed, signed and returned to the <br /> Heafth and Safety Representative within 24 hours. The Heatth and Safety Representative will <br /> forward a copy to Corporate Health and Safety. nn <br /> ' U GROUNDWATER <br /> '` l TECHNOLOCI' <br />