Form 000.653.

F0117
Monthly Incident Experience Report (MIER)

Check the appropriate project classification:

Self Perform/Construction Management Joint Venture LLC
Current Reporting Period: Last Report
SECTION A - PROJECT/OFFICE INFORMATION
SAP/Project No. and Charge No.: Client Name/Type of Business:

Project Name: P2S Business Unit/Group:

Project/Office Location: (County-U.S. Only) (Country)

-
Mailing Address (Post Office): Physical/Shipping Address:

HSE Manager: Phone No. Fax No.: Email address:

Site Manager: Phone No. Fax No.: Email address:

Construction Operations Manager: Manager of Projects: Date of last Corporate HSE Audit: Project Start Date and Estimated End Date:

Safe Work Hours To Date: Start Date For Safe Work Hours: Is this a Union Site? GIMS No.:

SECTION B - SELF-PERFORM PROJECT SAFETY STATISTICS

SELF-PERFORM CURRENT MONTH FY TO DATE PROJECT TO DATE CURRENT MONTH FY TO DATE PROJECT TO DATE

1. No. of Staff Employees 8. DART-R (Restricted Workday Cases)

2. No. of Staff Employees Work Hours 9. Days of Restricted Work

3. No. of Craft Employees 10. DART (Line 6 + Line 8)

4. No. of Craft Employees Work Hours 11. Medical Treatment Cases

5. Fatalities 12. TOTAL RECORDABLE CASES

6. DART-L (Lost Workday Cases) 13. First-Aid Cases

7. Days Away From Work 14. Near-Miss Cases

SECTION C - JOINT VENTURE/LLC SAFETY STATISTICS

JOINT VENTURES CURRENT MONTH FY TO DATE PROJECT TO DATE LLC CURRENT MONTH FY TO DATE PROJECT TO DATE

1. No. of Joint Venture Employees 12. No. of LLC Employees

2. No. of Joint Venture Work Hours 13. No. of LLC Work Hours

3. No. of Joint Venture Fatalities 14. No. of LLC Fatalities

4. Joint Venture DART-L Cases 15. LLC DART-L Cases

5. Joint Venture Days Away From Work 16. LLC Days Away From Work

6. Joint Venture DART-R Cases 17. LLC DART-R Cases

7. Joint Venture Days of Restricted Work 18. LLC Day of Restricted Work

8. Joint Venture Medical Treatment Cases 19. LLC Medical Treatment Cases

9. JV TOTAL RECORDABLE CASES 20. LLC TOTAL RECORDABLE CASES

10. Joint Venture First-Aid Cases 21. LLC First-Aid Cases

11. Joint Venture Near-Miss Cases 22. LLC Near-Miss Cases

SECTION D - SUBCONTRACTOR SAFETY STATISTICS

SUBCONTRACTOR INFO SELF/JV/LLC CURRENT MONTH FY TO DATE PROJECT TO DATE CURRENT MONTH FY TO DATE PROJECT TO DATE

1. No. of Subcontractors 7. Days of Restricted Work

2. Work Hours 8. DART (Line 4 + Line 6)

3. Fatalities 9. Medical Treatment Cases

4. DART-L (Lost Workday Cases) 10. TOTAL RECORDABLE CASES

5. Days Away From Work 11. First-Aid Cases

6. DART-R (Restricted Workday Cases) 12. Near-Miss Cases

MONTH FTD PTD MONTh FYTD PTD

Number of non-work-related deaths Number of investigations performed

P2S P2S
Subcontractor Subcontractor

Copyright © 2009, Fluor Corporation. All Rights Reserved. Page 1 of 2 Health, Safety, and Environmental
Form Date: 06Nov2009
 Form 000.653.F01
®
Monthly Incident Experience Report (MIE

SECTION E - PROJECT/OFFICE HSE STATISTICS (SELF-PERFORM AND SUBCONTRACTORS)

CURRENT FY TO DATE PTD CURRENT

1. Vehicle Accident (Fluor-owned/leased) 6. Regulatory Agency Involvement (unplanned)
Damage > $1000 OSHA
Damage < $1000 EPA
2. Property Damage (nonvehicular) Other National
Fluor Property State/Territory
Client Property Local/County/City
Third Party 7. Encounter with Contaminated Soil (unplanned)
3. Spill/Release Resulted in work stoppage > 1 day
> 1 gallon 8. Incident Involving EMS Response
> Reportable Quantity Fire
4. Fire (unplanned) Ambulance
5. Potential Chemical Exposure (unplanned) Police
Asbestos 9. Notice of Deficiency or Violation (Describe)
Welding Fumes Air Polllution
Refractory Ceramic Fibers (RCFs) Water Pollution
Silica Solid Waste Disposal
Nuisance Dust Hazardous Waste Disposal
Other Other
Comments:

Note: This form is referenced in Practices 000.653.0020, 000.653.1002, 000.653.1100, 000.653.1202, 000.653.1203, and 000.653.2000.

Copyright © 2009, Fluor Corporation. All Rights Reserved.

Form Date: 06Nov2009
Page 2 of 2 Health, Safety, and Environmental
 Form 000.653.F0117
y Incident Experience Report (MIER)

FY TO DATE PTD

Copyright © 2009, Fluor Corporation. All Rights Reserved.

Form Date: 06Nov2009
Page 2 of 2 Health, Safety, and Environmental
 Form 000.653.F0134
Monthly Subcontractor Incident Summary Report (MSISR)
®
Construction Management Self-Perform/Joint Venture

Project Name: Location: Project No.: Fluor Business Unit/Group: Month

Subcontractors
DART-R
(Include Tier Subcontractors) DART (DART-L + DART-L (Lost Days Away From Days of Other Recordable Total Recordable
Labor Posture Employee Hours (Restricted First-Aid Cases Near Miss Cases Fatalities
No. of DART-R) Time Cases) Work Restricted Work Cases * Cases
You may enter here the total Workday Cases)
Empl.
number of subs as opposed to individual
UNION NON MONTH FYTD MONTH FYTD MONTH FYTD MONTH FYTD MONTH FYTD MONTH FYTD MONTH FYTD MONTH FYTD MONTH FYTD MONTH FYTD MONTH FYTD
subs

Total Union Statistics

Total Nonunion Statistics

Total Project Subcontractor Statistics

Provide details of fatalities.

Prepared By: Phone No.: Reviewed and Approved By: Date:

* Formerly known as "medical treatment cases" (MTC).

Note: This form is referenced in Practices 000.653.1202 and 000.653.1203.

Copyright © 2009, Fluor Corporation. All Rights Reserved.

Form Date: 06Nov2009 Page 1 of 1 Health, Safety, and Environmental
 Form 000.653.F0193
Project Incident Log

Project Name: Location:

Business Unit/Group: Year:

Project Incident Log (formerly Daily Incident Report must be maintained throughout the year with amendments and additions to entries made where appropriate beyond end of report month. Transmit to Project Manager, Business Unit HSE Lead, and Regional HSE
Lead as directed.

Incident Contractor, Company, Where Did Injury Occur?

GIMS Describe How Injury Occurred/What Closed Out No. of Days No. of
Date Classification or What Was Employee Doing Before What Body Part Was Injured? Action Taken to Prevent Recurrence Days Restricted
Incident No. Contributed to Incident? Yes/No Lost
** Injured Person's Name Incident?

Prepared by: Contact: Reviewed by:

** Incident Classification: Fatality; DART-L (lost time case); DART-R (work restricted case); ORC ("other" recordable case [formerly known as medical treatment case {MTC}]); FAC (first-aid case); Near Miss; Environmental.
Note: This form is referenced in Practices 000.653.1002, 000.653.1202, and 000.653.1203.

Copyright © 2009, Fluor Corporation. All Rights Reserved.

Form Date: 06Nov2009
Page 5 of 5 Health, Safety, and Environmental