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(ATTACHMENT 9) a <br /> ,SECOR r Ry <br /> /ILLNESS REPORT se additional ace as necess <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?(INCLUDE ADDRESS) s <br /> ON EMPLOYER'S PREMISES? YES_ NO_ PROJECT.NAMEINO. <br /> WHAT WAS EMPLOYEE DOING WHEN INCIDENT OCCURRED?(BE SPECIFIC) + <br /> HOW DID THE INCIDENT OCCUR?(DESCRIBE FULLY) - <br /> i <br /> i <br /> WHAT STEPS COULD BE TAKEN TO PREVENT SUCH AN INCIDENT? <br /> OBJECT OR SUBSTANCE THAT DIRECTLY CAUSED INCIDENT" <br /> i <br /> DESCRIBE THE INJURY OR ILLNESS PART OF BODY AFFECTED- ' <br /> NAME AND ADDRESS OF PHYSICIAN <br /> IF HOSPITALIZED, NAME AND ADDRESS OF HOSPITAL <br /> LOSS OF ONE OR MORE DAYS OF WORK? YES/NO— IF YES-DATE LAST WORKED <br /> HAS EMPLOYEE RETURNED TO WORK? YES/NO IF YES-DATE RETURNED ._ <br /> DID EMPLOYEE DIE?YES/NO IF YES, DATE <br /> COMPLETED BY(PRINT) EMPLOYEE SIGNATURE <br /> (Supervisor or Site Health&Safety Officer) <br /> DATE <br /> SIGNATURE - - <br /> a " PIC SIGNATURE <br /> DATE <br /> 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 completcd report must <br /> be reviewed and signed by the Principal-in-Charge and transmitted to Corporate Health and Safety and the Health& Safety Coordinator within 24 hours of the <br /> incidera,even if employee is not available to review and sign. Employee or employee's doctor must submit a copy of,the doctor's report to Corporate Health and <br /> Safety within 24 hours of the initial exam and any subsequent exams. For field injuries,submit a copy of the Health and Safety Plan. <br />