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Injury and Illness Prevention Program 2.22 Appendix C -Accident Report and Investigation Form ❑ Roux Environmental Engineering and Geology, D.P.C. ❑ Roux Associates, Inc. ❑ Remedial Engineering, P.C. ACCIDENT REPORT Brian Hobbs, Corporate Health and Safety Manager Cell: (631)807-0193; Office: (631)630-2416 PART 1: ADMINISTRATIVE INFORMATION Project#: Immediate Verbal Notifications Given REPORT STATUS(time due): Project Name: To: Project Location(street address/city/state): ❑ Initial(24 hr) ❑ Final(5-10 days) Date: Date: Client Corporate Name/Contact/Address/Phone#: Corporate Health&Safety Dyes ❑No Accident Report Delivered To: Office Health&Safety Dyes ❑No Corporate Health&Safety Dyes ❑No Office Manager Dyes ❑No Office Health&Safety Dyes ❑No Project Principal Dyes ❑No Office Manager Dyes ❑No Project Manager Dyes ❑No Project Principal Dyes ❑No Client Contact Dyes ❑No I Project Manager Dyes ❑No REPORT TYPE: ❑ Loss ❑ Near Loss Estimated Costs: $ OSHA CASE#Assigned by Corporate Health&Safety if Corporate Health&Safety Confirmed Final Accident Report Applicable: Dyes ❑No DATE OF INCIDENT: TIME INCIDENT OCCURRED: INCIDENT LOCATION—City,State,and Country(If outside U.S.A.) ❑AM ❑PM INCIDENT TYPES: (Select most appropriate if Loss occurred.) From lists below, please select the option that best categories the incident. When selecting an injury or illness,also indicate the severity level. ❑INJURY ❑ILLNESS OTHER INCIDENT TYPES -------------------------Severity Level---------------------------- ❑Spill/Release ❑Misdirected Waste ❑Consent Order ❑NOV ❑Fatality ❑First Aid ❑Medical Material involved: ❑Property Damage ❑Exceedance El Restricted Work ❑Lost Time Treatment Quantity(U.S.Gallons): ❑Motor Vehicle ❑Fine/Penalty ACTIVITY TYPE(Check most appropriate one.) INJURY TYPE(Check all applicable.) BODY PART AFFECTED(Check all applicable.) ❑CAMP ❑Gauging ❑Subsurface ❑Abrasion ❑Occupational illness ❑Respiratory ❑Shoulder El Face ❑Construction ❑O&M Clearance [:]Amputation ❑Puncture ❑Neck ❑Arm ❑Leg ❑Drilling ❑Other Soil Work ❑Trucking ❑Burn ❑Rash ❑Chest ❑Wrist ❑Knee ❑Driving (e.g.Compaction) ❑Waste Mgmt. ❑Cold/Heat Stress El Repetitive Motion ❑Abdomen ❑Hand/Fingers ❑Ankle ❑Excavation ❑Sampling ❑Work Area Prep. ❑Inflammation ❑Sprain/Strain ❑Groin El Eye ❑Foot/Toes /Trenching ❑Site Walk/Inspection ❑Other I El Laceration ❑Other I El Back ❑Head ❑Other I. PERSONS DIRECTLY/INDIRECTLY INVOLVED IN INCIDENT Attach additional information as necessary/applicable.) Name/Phone#of Each Designate: As applicable, As applicable, As applicable, Person Directly/Indirectly Roux/Remedial Employee Current Occupation; Employer Name; Supervisor Name;and Involved in Incident: Roux/Remedial Subcontractor Yrs in Current Occupation; Address;and Phone#: Client Employee Current Position;and Phone#: Client Contractor Yrs in Current Position: Third Party 1) 2) 1/2019 Corporate Health and Safety Management Program I ROUX