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• ATTACHMENT 4 <br /> SECOR INJURYALLNESS REPORT <br /> DATE OF INCIDENT CASE NO TIME OF DAY <br /> EMPLOYEE NAME DATE OF BIRTH <br /> HOME ADDRESS PHONE NO <br /> SEX MALE- FEMALE . AGE— JOB TITLE SOCIAL SECURITY NO <br /> OFFICE LOCATION DATE OF HIRE <br /> WHERE DID INCIDENT OCCUR-7(INCLUDE ADDRESS) <br /> ON EMPLOYER'S PREMISES? YES— NO— PROJECT NAMEINO <br /> WHAT WAS EMPLOYEE DOING WHEN INCIDENT OCCURREDy(BE SPECIFIC) <br /> HOW DID THE INCIDENT OCCUR"(DESCRIBE FULLY) <br /> WHAT STEPS COULD BE TAKEN TO PREVENT SUCH AN INCIDENT) <br /> OBJECT OR SUBSTANCE THAT DIRECTLY CAUSED INCIDENT? <br /> DESCRIBE THE INJURY OR ILLNESS PART OF BODY AFFECTED <br /> NAME AND ADDRESS OF PHYSICIAN <br /> IF HOSPITALIZED,NAME AND ADDRESS OF HOSPITA <br /> LOSS OF ONE OR MORE DAYS OF WORKS YESINO_ IF YES-DATE LAST WORKED <br /> HAS EMPLOYEE RETURNED TO WORKS YES/NO IF YES-DATE RETURNED <br /> DID EMPLOYEE DIES YES/NO IF YES DAT <br /> COMPLETED BY(PRINT) EMPLOYEE SIGNATURE <br /> (Supervisor or Site Health&Safety Officer) <br /> DATE <br /> SIGNATURE <br /> PIC SIGNATURE <br /> DATE DATE <br /> This report must be completed by the employee S Supervisor or Site Health and Safety Officer immediately upon learning of the incident The completed report must <br /> be reviewed and signed by the Principal-in-charge and transmitted to Corporate Health and Safety and Health&Safety Coordinator within 24 hours of the incident <br /> even if employee is not available to review and sign Employee or employees doctor must submit a copy of the doctor's report to Corporate Health and Safety within <br /> 24 hours of the initial exam and any subsequent exams For field injuries, submit a copy of the Health and Safety Plan A detailed synopsis of events including <br /> tive action to be taken must be submitted by the PIC to Corporate Health&Safety within I week of the injury/illness <br /> REV 11 17-95 <br /> 1\ARCO1A932\ssp doc <br />