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Injury and Illness <br /> Prevention Program 2.22 <br /> II.PERSONS INJURED IN INCIDENT Attach additional information as necessary/applicable.) <br /> Name/Phone#of Each Designate: As applicable, As applicable, As applicable, Description of Injury: <br /> Person Injured in Incident: Roux/Remedial Employee Current Occupation; Employer Name; Supervisor Name;and <br /> Roux/Remedial Subcontractor Yrs in Current Occupation; Address;and Phone#: <br /> Client Employee Current Position;and Phone#: <br /> Client Contractor Yrs in Current Position: <br /> Third Party <br /> 1) <br /> 2) <br /> III.PROPERTY DAMAGED IN INCIDENT(Attach additional information as necessary/applicable.) <br /> Property Damaged: Property Location: Owner Name,Address&Phone#: Description of Damage: Estimated Cost: <br /> 1) <br /> 2) $ <br /> IV.WITNESSES TO INCIDENT(Attach additional information as necessary/applicable.) <br /> Witness Name: Address: Phone#: <br /> 1) <br /> 2) <br /> PART 2: WHAT HAPPENED AND INCIDENT DETAILS <br /> PROVIDE FACTUAL DESCRIPTION OF INCIDENT(e.g.,describe loss/near loss,injury,response/treatment). <br /> I. AUTHORITIES/GOVERNMENTAL AGENCIES NOTIFIED(Attach additional information as necessary/applicable.) <br /> Authority/Agency Notified: Name/Phone#/Fax#of Person Address of Person Notified: Date&Time of Notification: Exact Information <br /> Notified: Reported/Provided: <br /> II. PUBLIC RESPONSES TO INCIDENT(if applicable) <br /> Response/Inquiry By: Entity Name: Name/Phone#of Respondent/ Address of Entity/Person: Date&Time of Response/Inquiry: <br /> check one Inquirer: <br /> ❑Newspaper <br /> ❑Television <br /> El Community Group <br /> []Neighbors <br /> ❑Other <br /> Describe Response/Inquiry: <br /> Roux/Remedial Response: <br /> (Check all that apply.)(Attach photos,drawings,etc.to help illustrate the incident.) <br /> ATTACHED INFORMATION: [-]Photo ❑Sketches ❑Vehicle Acord Form ❑Police Report ❑Other <br /> Name(s)of person(s)who prepared Initial and Final Title(s): Phone number(s): <br /> Report: <br /> PART 3: INVESTIGATION TEAM ANALYSIS <br /> 1/2019 Corporate Health and Safety Management Program I ROUX <br />