TIME LOST DUE TO INJURY SUMMARY

PROJECT: DATE: COMPLETED BY:

Form: 1020 WEEK ENDING: SIGNED:

To be filled out weekly by the Project Manager or HS Manager.

THIS WEEK THIS WEEK PROJECT TO DATE Total Time Lost

Employees & HOURS WORKED Worked Injury Worked Injury as a % of total
External Service Providers Mon Tue Wed Thu Fri Sat Sun Total Hrs lost time Total Hrs lost time Time Worked
Employees Name: 0 0 0 ###
Employees Name: 0
Employees Name: 0 0 0 ###
Employees Name: 0 0 0 ###
Employees Name: 0 0 0 ###
Employees Name: 0 0 0 ###
Employees Name: 0 0 0 ###
Sub-Contractor Name: 0 0 0 ###
Sub-Contractor Name: 0 0 0 ###
Sub-Contractor Name: 0 0 0 ###
Sub-Contractor Name: 0 0 0 ###

TIME LOST DUE TO INJURY DETAILS

NAME OF WORKER PROJECT NAME NATURE OF INJURY CURRENT STATUS

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