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ATTACHMENT 3 /lair Incident Investigation / Near-Miss Investigation Report Consider using the Root Cause Analysis PROACTIVELY to avoid incidents and near misses. INCIDENT TYPE (To be filled in by Human Resources Department) Date of Incident: ❑ Fatality ❑ Industrial Non- ❑ Spill/Leak ❑ General Liability �+ • ❑ Recordable Lost Workday ❑ Product Integrity ❑ Criminal Activity ❑ LW Restricted Duty ❑ Non-Industrial ❑ Equipment ❑ Notice of Violation ❑ OSHA Medical or Illness w/o LW ❑ Off-the-Job Injury ❑ Business Interruption ❑ Near Miss ❑ First Aid ❑ MVA ❑ Fire The investigation of the incident by the employee's supervisor or Site Health and Safety Officer must begin immediately. Human Resources and Corporate Health & Safety must be informed immediately and in no case longer than 24 hours after the incident. This report must be completed as soon as possible. It must be reviewed and signed by the Principal and e-mailed or faxed to the Vice President of Human Resources, and Corporate Health and Safety (numbers below), 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. Contact information at end of report. EMPLOYER (Include sub-contractors, or other employers on our sites) Company Name: I Work Location Address where incident occurred: Project Name: EMPLOYEE ,., Name: - - --.._.._..............................._..........._..._..........................._.................._._..._................._......................................................._............................ Employment Status: ❑ Full-Time ❑ Part-Time ❑ Hourly-As-Needed 1 How long in present job? i INJURY OR ILLNESS INFO a Where did incident/near miss occur? (number,street,city,state,zip): --------.......................--........---.-__..__.........._..._...--_..._....__....._........_-----_ ' County: j On Employer's premises? ❑ Yes ❑ No ......_....._.._._....._..._..._....._......_.............._................................._................................I....._................._.__......_............ 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,name and address of hospital: Phone No.: ......._.....-_-- ._.._._.----._...................................._.........._ --._...._._..........- - _ -...................... Date of injury or onset of illness(MM/DD/YYYY) _! / Time of event or exposure: _--- - ❑ AM ❑ PM Time employee began work: ❑ AM ❑ Did employee lose at least one full shift's work? PM ❑ No ❑ Yes, 1 st date absent(MM/DD/YYYY) n. _..._.... _ ------.._._._._.._.._.................._..._......._..._.................._....._-.............-......._............---- ......................... 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: (MM/DD/YYYY) - —.—._._._......._........_--._.____�.__.___ -. __.__.._._....._...._._._.__._._._...-------_-..._---- ----------- ......To whom reported: ` Other workers injured/made ill in this event? ❑ Yes ❑ No j PG&E SECOR International Incorporated SECOR Project No.050T.50234.00.0003 PG&E French Camp HASPB.doc 79