Laserfiche WebLink
A <br />APEX <br />INCIDENT REPORT FORM <br />Date of Incident: <br />Time employee began work: <br />Time of event or exposure: <br />Incident Type <br />0 Fatality 0 Industrial Non- <br />Recordable 0 Spill/Leak 0 General Liability <br />D Lost Workday (LVV) Li Non-Industrial 0 Product Integrity 0 Criminal Activity <br />D LW Restricted Duty 0 Off-the-Job Injury 0 Equipment 0 Notice of Violation <br />Li OSHA Illness w/o LW Li Motor Vehicle <br />Accident (MVA) 0 Business Interruption 0 First Aid <br />Li Fire 0 Li ij <br />0 0 0 0 <br />The investigation of the incident by the employee's supervisor or Site Health and Safety Coordinator must begin <br />immediately. Human Resources and Corporate Health & Safety must be informed immediately and in no case longer <br />than 24 hours after the incident. This report must be completed as soon as possible. It must be reviewed and signed by <br />the Principal and e-mailed or faxed to the Human Resources Manager, and Corporate Health and Safety (numbers <br />below), even if employee is not available to review and sign. Employee or employee's doctor must submit a copy of the <br />doctor's report to Human Resources within 24 hours of the initial exam and any subsequent exams. Contact information <br />at end of report. <br />Employer (include Apex-SGI subcontractors) <br />Company Name: <br />Address: <br />City, State, Zip: <br />Project Name: <br />Project Number: <br />Employee (include Apex-SGI subcontractors) <br />First and Last Name: <br />Home Address: <br />City, State, Zip: <br />Employment Status: <br />Date of Hire: <br />Page 1 of 2