REGULATION FOR COORDINATION OF ACTIVITIES ON WIND FARM

Version 01: 20/10/06

ANALYSIS AND INVESTIGATION OF ACCIDENTS AND

WORK-RELATED ILLNESSES FORM

Page 1 of 1
Form RCA-12

CONTRACTOR INFORMATION:
COMPANY NAME:
Contracted by:

PERSON SUFFERING THE ACCIDENT:

Name of employee:
Occupation:

INFORMATION REGARDING THE INCIDENT:

Date of incident:

Day of the week:

Time:

Location of
incident:
Task being performed at moment of incident:
Names of possible witnesses:
Consequences:
Incident
Accident without Sick Leave

Description of injuries to persons:

Accident with Sick Leave

Work-related Illness
Accident

Description of damage to things:

Detailed description of the incident:

POSSIBLE CAUSES OF THE INCIDENT:

PREVENTIVE ACTIONS PROPOSED:

At

on

Signed by The representative of the

Contractor, Subcontractor or Freelance
Worker:

of