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Injury and Illness <br /> Prevention Program 2.22 <br /> HEALTH & SAFETY NEAR LOSS <br /> ROUX REPORT FORM <br /> ❑ Roux Environmental Engineering and Geology, D.P.C. <br /> ❑ Roux Associates, Inc. ❑ Remedial Engineering, P.C. <br /> (Check applicable company name) <br /> PART 1: ADMINISTRATIVE INFORMATION <br /> Office: ❑ New York ❑ Massachusetts ❑ New Jersey ❑ Illinois ❑ CA- Los Angeles ❑ CA-Oakland <br /> Project Manager: Project Principal: <br /> Project Name: Project Location: <br /> PART 2: NEAR LOSS INCIDENT DETAILS <br /> Date\Time Occurred (MM/DD/YYYY HH:MM): Date\Time Submitted (MM/DD/YYYY HH:MM): <br /> NEAR LOSS INCIDENT TYPE-What could have happened?-Select all that apply(1-7) <br /> 1. ❑ Fire/Explosion 3. ❑ Security(e.g., 4. ❑ Environmental (Spill, permit 6. ❑ Property/Equipment <br /> 2. ❑ Injury/Illness theft,trespassing, exceedance, etc.) Damage <br /> vandalism) 5. ❑ Transportation of personnel (vehicle 7. ❑ Business Interruption <br /> accident <br /> Event Leading to Potential Injury/Illness: <br /> Job Task*: I Equipment Involved*: <br /> WHAT HAPPENED? Do not include individuals' names. Ensure photos, sketches, etc. are not personally identifiable unless written <br /> consent has been obtained. <br /> Summary(1-2 sentences. Provide brief description of the incident. Provide facts only, no speculation or opinion): <br /> Incident Details (Brief factual details of what,where,when; include photos,sketches,etc. as attachments): <br /> Immediate Corrective Actions Taken: <br /> Could this have resulted in a SIF? ❑ Yes ❑No <br /> A potential SIF is defined as likely to have caused an injury resulting in significant physical body damage with probable long term and/or <br /> life altering complications. <br /> INCIDENT INVOLVED: <br /> Roux Employee: ❑ Yes ❑ No Subcontractor Company Name: <br /> INVESTIGATION TEAM <br /> NAME JOB TITLE NAME JOB TITLE <br /> 03/2025 Corporate Health and Safety Management Program I ROUX <br />