Laserfiche WebLink
GROUNDWATER TECHNOLOGY, INC. <br /> Accident/Incident/Bear Miss Report <br /> D.O.B. <br /> Employee's Name: _ D.O.H. <br /> ,ddress: SS# ��------ <br /> Job Title; Superviscrs's Name: <br /> Office Location: <br /> Location at Time of Incident: <br /> Date/Time of Incident: <br /> Description: Describe clearly how the accident occurred: <br /> Physical Chemical <br /> Was Incident: Exposure: Dermal <br /> Part(s) of body affected: Inhalation <br /> right left <br /> Ingestion ^�- <br /> 2) <br /> Witnesses: 1)� <br /> !onditions/acts contributing to this incident: <br /> Explain specifically the corrective action you have taken to prevent a <br /> recurrence: <br /> Did the injured go to a doctor? Where. <br /> When? <br /> Did injured go to a hospital? Where. <br /> When? <br /> Signatures: <br /> Reporting <br /> Employee Manager Regional H&S Manager <br /> -- __ ---Date <br /> Date Date <br /> feted and returned within 5 working days to Regional Health & Safety Manager, who will forwar a copy o - <br /> - �.M115 form must be comp - . <br /> corporate Health & safety manager at ELO. <br />