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• GENESIS ENGINEERING&tlRLOPMENi <br /> INJURY REPORTING FORM <br /> (Continued) <br /> Was the activity being performed under a Health and Safety Plan? <br /> Yes No_ If yes, attach a copy of the plan. <br /> Provide a list of any personal protective clothing and equipment used by the employee at the <br /> time of the exposure/injury incident. <br /> Did any aspect of personal protective clothing and equipment contribute to the exposure/injury <br /> incident? Yes No If yes,please explain. <br /> Are measures available that may help prevent a repeat of a similar exposure/injury incident? <br /> Yes No If yes,please explain. <br /> Describe property damage, if applicable. <br /> Name,job position, office location of individual(s) completing this exposure/injury incident <br /> report. <br /> Date: <br /> Project Manager Signature <br /> Date: <br /> Employee Signature <br /> Date: <br /> Site Safety Coordinator Signature <br /> Date: <br /> Site Technical Coordinator Signature <br /> • <br /> 2of2 <br />