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FORM HS-502 <br /> WC HEALTH AND SAFETY INCIDENT REPORT <br /> Project Name: TYPE OF INCIDENT (Check all applicable ftems) <br /> Project Number: ❑ Illness ❑ Fire, 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 /> PROJECT NAME: LOCATION: <br /> DESCRIPTION OF INCIDENT (describe what happened and possible cause. Identify individuals involved, <br /> witnesses, and their affiliations; and describe emergency or corrective action taken.) <br /> Reporter: <br /> Print Name Signature Date <br /> Reporter must deliver this report to the Operating Unit Health & Safety Officer within 24 hours of the <br /> reported incident for medical treatment cases and within five days for other incidents. <br /> Reviewed by: <br /> Operating Unit Health & Safety Offflcer Date <br /> Distribution: <br /> Corporate Health and Safety Administrator <br /> Corporate Health and Safety Officer <br /> _ Project Manager <br /> Personnel Office (medical treatment cases only) <br />