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I INCIDENT REPORT <br /> Name/Subject: <br /> Badge #: Date: <br /> Foreman's Name: DOC #: <br /> File #: <br /> (These forms must be attached to each accident or injury report) <br /> ❑ Formal Near Miss/Incident Investigation Report (5050-24.003) Page 1 of 9 <br /> ❑ Employee Statement Page 2 of 9 <br /> ❑ Foreman's Statement Page 3 of 9 <br /> Page 4 of 9 <br /> ❑ Copy of JSA for the date of injury. (Attach to Foreman' Statement) <br /> ❑ Copy of Safety Work Permit. (If, applicable) <br /> ❑ Witness Statement (if, applicable) Page 5 of 9 <br /> ❑ Vehicle Accidents (if applicable) Page 6 of 9 <br /> ❑ Environmental of chemical hazard incident (if applicable) Page 7 of 9 <br /> ❑ Utility Damage (if applicable) Page 8 of 9 <br /> ❑ HSE Professional's Summary Page 9 of 9 <br /> ❑ Safety Investigation Report (for Document Control) <br /> ❑ W/C Worksheet <br /> ❑ Drug Screen (if required) Date: <br /> ❑ Entered on Accident/Incident Log ( if required) Date: <br /> (Attach only if,medical treatment is refused) <br /> ❑ Refusal of Medical Treatment (if applicable) <br /> MEDICAL (INCLUDES ALL QE THE ABOVE AND THE FOLLOWING) <br /> ❑ Insurance Claim Form or(E—1) <br /> ❑ Medical Authorization for Medical Care or Testing <br /> ❑ Release for Medical Opinion and Return to Work(if applicable) <br /> ❑ Any Medical information from Doctors office. <br /> Equipment(Property Damage <br /> ❑ Equipment Inspection Type of Equipment: <br /> Notifications <br /> ❑ Reported to Carrier on Date: Via: <br /> Reported by: Contact Name: Ext#: <br /> ❑ Reported to Site Manager Date: Via: <br /> Reported by: <br /> ❑ Reported to Director HSE Date: Via: <br /> Reported by: <br /> Reviewed for Completeness <br /> (Make sure that all forms have signatures along with date and times are correct.) <br /> Reviewed by: Date: <br /> Reviewed by: Date: <br /> Reviewed by: Date: <br />