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HEALTH AND SAFETY INCIDENT REPORT <br /> Project Name: TYPE OF INCIDENT(Check all applicable items) <br /> Project Number: _ Illness _ Fuc,Explosion,Flash <br /> Date of Incident: _ Injury _ Unexpected exposure <br /> Time of incident: _ Property Damage _ Vehicular Accident <br /> Location: _ Health&Safety Infraction <br /> Other (describe) <br /> DESCRIPTION OF INCIDENT(describe what happened and possible causes,identify individuals involved,witnesses and <br /> their affiliations and emergency or corrective action taken) <br /> Reporter: <br /> Print Name Signature Due <br /> Reporter must deliver this report to the operating unit health and safety officer within 24 hours of the reported incident for <br /> medical treatment cases and u-ithin five days for other incidents. <br /> Reviewed by: <br /> Operating Unit Health and Safety Officer Date <br /> Distribution: <br /> - Corporate Health and Safety Administrator - Corporate Health and Safety Officer <br /> - Project Manager - Personnel Office (medical treatment cases only) <br /> 80500000 H:\I{EALTHtFNLHSP April 21, 1997 <br /> FEMA UST. Fuel Generic HSP 34 <br />