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V Attachment 2 M Incident Investigation/, • ' Near-Miss / • I Investigation Date of Incident: ❑ Fatality ❑ Industrial Non-Recordable ❑ Spill/Leak ❑ General liability ❑ 'Lost Workday ❑ Non-Industrial ❑ Product Integrity ❑ Criminal Activity ❑ LW Restricted Duty ❑ Off-the-Job Injury ❑ Equipment ❑ Notice of Violation ❑ OSHA Medical or Illness w/o LW ❑ MVA ❑ Business Interruption ❑ Near Miss ❑ First Aid ❑ Fire (TO BE COMPLETED BY HR) 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 be reviewed and signed by the Principal-In-Charge and e-mailed or faxed to the Vice President of Human Resources, _ - Corporate Health and Safety and the Health&Safety Coordinator within 24 hours of the incident,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 Human Resources within 24 hours of the initial exam and any subsequent exams. Phone: 619-718-9429,Fax:619-296-2006,E-Mail:mhanis@seconcom. Company Name: Work Location Address where incident occurred: Project Name: 1. Name: SSN: Birthdate: Employment Status: ❑ Full-Time ❑ Part-Time ❑ Hourly-As-Needed How long in presentjob? INJURY Olt ILLNESS INFO Where did incident/near miss occur?'.(number,street,city,state,zip): -' County: On Employer's premises? ❑ Yes ❑ No Specific activity the employee was engaged in when the incident/near miss occurred: All equipment,materials,or chemicals the employee was using when the incident/near miss occurred(e.g.,the machine employee struck against or which struck employee;the vapor inhaled or material swallowed;what the employee was lifting,pulling,etc.): Describe the specific injury or illness(e.g.,cut,strain,fracture,skin rash,etc.): Body part(s)affected(e.g.,back,left wrist,right eye,etc.): Name and address of Health Care Provider(e.g.,physician or clinic): Phone No.: If hospitalized,time and address of hospital: _ Pb'one No.: Date of injury or onset of illness(MM/DD/YYYY) / / Time of event or exposure: ❑ AM ❑ PM Time employee began work: ❑ AM [I PM Did employee lose at least one full shift's work? .. ❑ No E] Yes,1st date absent(MM/DD/YYYY) Has employee returned to work? ❑Regular work ❑ Restricted work ❑ No,still off work ❑ Yes,date returned(MM/DD/YYYY) Did employee die? ❑ No ❑ Yes,date(MM/DD/YYYY) Date employer notified of incident/near miss: (MMMD/YYYY) / / To whom reported: Other workers injured/made ill in this event? Yes ❑ No SECOR International Incorporated 15 HASP-drilling