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21 <br /> WiS— <br /> h <br /> 1 FORM HS-502 <br /> SWC HEALTH AND SAFETY INCIDENT REPORT <br /> Project Name' TYPE OF INCIDENT(Check all applicable Items) <br /> fa Project Numbr,r: IJ Illness ❑ Fire, explosion,flash <br /> Date of Incident: <br /> ❑ Injury ❑ Unexpected exposure <br /> )` Time of Incident: ❑ Property Damage ❑ Vehicular Accident <br /> i .. <br /> l.ocailon: ❑ Health&Safety infraction <br /> 1�A <br /> ` ❑ Other(de:crlbe) <br /> PROJECT NAME: LOCATION: <br /> F Y DESCRIPTION OF INCIDEVT(describe what happened and possible cause.Identify inaividuais involved, <br /> witnesses.and their affifations;and describe emergency or corrective action taken.) <br /> is 4 <br /> Reporter: <br /> Pram Name . Signature Dat` <br /> Reporter must deliver this report to the Operating Unit Health&Safety Officer within 24 hours of the <br /> reported incident for medical treatment cases and within five days for other incidents. <br /> Reviewed by: <br /> Operating Unit Health S Safety Offficer Dale <br /> i Distribution: <br /> _ _ Corporate Health and Safety Administrator <br /> Corporate Health and Safety Officer <br /> Project Manager <br /> _ Personnel Office(medical treatment cases only) <br /> A <br />