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Incident Investigation All incidents need to be investigated. The supervisor of the employee involved in the incident is responsible for conducting the investigation in consultation with the director of Health & Safety (H&S) and, when appropriate, ensuring that corrective actions are taken with the input of H&S. The depth and complexity of the investigation will vary with the circumstances and seriousness of the incident. A thorough investigation may identify previously overlooked physical, environmental, or process hazards, the need for new or more extensive safety training, or unsafe work practices. The supervisor should complete sections 1 to 13, sign and date the form, and then forward the form to the Project Manager or Health & safety Director for review and approval. Once complete, a copy of the form must be sent to Human Resources (fax: 714-893-5122; email: dvaldivia@icsinc.tv). For additional guidance, please call Daisy Valdivia 714- 893-6366. 1-8 Background Information on Injured Person (if any): This form must be used only for incidents involving ICS employees. Accidents involving outside contractors or site visitors must be reported to Health & Safety Director immediately. 9. Specific Location: : Self-explanatory 10. Witnesses: Self-explanatory 11. Description of Incident: Most accidents result from an accumulation of events. An accurate, factual description of the accident and the events leading up to it can be very helpful. This chronological sequence can be studied to determine how each event may have contributed to the accident. Include photos or drawings of the accident site, if these will be useful to the investigation. 12. Factors: Factors, if any, are the conditions in the workplace or actions that contributed to the occurrence of this accident. Examples might include unguarded machinery, broken tools, slippery floors, not following established procedures, or insufficient training or maintenance. 13. Corrective Actions: List actions or steps that could be taken to control or eliminate the likelihood of a recurrence. Include not only those that can be accomplished right away (e.g., providing personal protective equipment, installing a machine guard), but also actions such as changes in policy or providing additional training. Health & Safety should be an integral part of any corrective actions. Please consult the Health & Safety Director andd/or Human Resources prior to implementing corrective actions. Page 2 of 2