Laserfiche WebLink
ATTACHMENT 4 <br /> SECOR YNJURYALLNESS REPORT <br /> DATE OF INCIDENT CASE NO TIME OF DAY <br /> EMPLOYEE NAME _ --_- _ DATE OF BIRTH - <br /> ROME ADDRESS PHONE NO <br /> SEX MALE_ FEMALE_ AGE .. JOB TITLE SOCIAL SECURITY NO <br /> OFFICE LOCATION DATE OF HI E. <br /> WHERE DID INCIDENT OCCURS(INCLUDE ADDRESS) <br /> ON EMPLOYER'S PREMISES') YES— NO— PROJECT NAME/NO <br /> WHAT WAS EMPLOYEE DOING WHEN INCIDENT OCCURRED?(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 HOSPITAT- — - --- <br /> LOSS OF ONE OR MORE DAYS OF WORKS YES/NO.._. 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,DA <br /> COMPLETED BY(PRINT) EMPLOYEE SIGNATURE <br /> (Supervisor or Site Health&Safety Officer) <br /> DATE <br /> SIGNATURE <br /> 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 completed report must <br /> be reviewed and signed by the Principal-m-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 employee's 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 /> co ective action to be taken must be submitted by the PIC to Corporate Health&Safety within 1 week of the injury/illness <br /> REV 11-17 95 <br />