ENGINEER’S STAMP: CONTRACTOR’S STAMP:

The Contractor declares that this submission has passed the contractor’s QA/QC procedure
and is in accordance with the requirements of the Contract.

Signature

AC Issue for Approval CZ CZ MPJ 20111106

AB Issue for Approval CZ FM 20110328
AA Issue for Approval CG Initials 20101213
REV DESCRIPTION PREPARED CHECKED APPROVED DATE

PÖYRY ENERGY AG

CONSORTIUM
AL - ARRAB CONTRACTING COMPANY LTD
SEPCOIII ELECTRIC POWER CONSTRUCTION CORPORATION

PROJECT: TITLE:
31002
LOCATION:
East Coast ACCIDENT REPORT AND INVESTIGATION PROCEDURE
PACKAGE:
“P” Power Plant
SCALE: DOCUMENT No.: REV:

None 0 0 - T A A - A B G - 1 0 7 0 0 7 - 0 0 AC

Engineer of Record Sheet 1 of

26
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SECTION INDEX

1 General ............................................................................................................................... 2
2 Injury Report ....................................................................................................................... 3
3 Reporting ............................................................................................................................ 4
4 Investigating Team/Committee ........................................................................................... 4
5 Investigation ....................................................................................................................... 5
5.1 General ........................................................................................................................ 5
5.2 Conducting the Investigation ........................................................................................ 5
5.3 Witnesses ..................................................................................................................... 5
5.4 Evidence ....................................................................................................................... 6
5.5 Photographs, Video Recordings, Drawings and Diagrams.............................................. 7
5.6 Accident Report Format ................................................................................................ 8
5.7 Accident Investigation Quick Checklist .......................................................................... 9
5.8 News Media Release..................................................................................................... 9
5.9 Summary .................................................................................................................... 10
5.10 Distribution of Reports................................................................................................ 10

1. General
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All incidents/accidents of the following, which occur at or in association with the Project,
will be thoroughly investigated.
 Occupational injuries, illnesses and first aid cases
 Vehicle or equipment accidents
 Property damage
 All fires
 Injury to non-project persons visiting the project
 Project employees injured on the project site proper
 Project employees injured away from the project site performing project duty
 Near Misses.

2. Injury Report

When a person is injured on the project to the extent that first aid treatment is needed, the
supervisor must ensure the following:
 The injured/ill employee is taken to the first aid post, and/or medical facility.
 Adequate first aid treatment has been rendered.
 A safety representative should accompany the injured employee.
 Upon completion of first aid treatment the injured/ill employee is returned to the work
site
 All first aid injuries/illnesses are to be documented

When a person is injured to the extent that an ambulance or medical treatment is required,
the supervisor must ensure the following:
 That the Project Medical Facility is notified and an ambulance is called immediately.
 The Safety Managers of subcontractor and PMO are notified immediately.
 Ensure medical treatment is administered throughout the emergency.
 That the injured is not moved. (unless further danger is present).
 Protect the injured from further injury.
 A member of the company’s safety department accompanies the injured in the
ambulance.
 Medical treatment is only to be administered by a licensed physician at the project
medical facility. Should further treatment be necessary the project physician must refer
the injured to an external medical facility.
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3. Reporting

In the event of an accident on the project, the injured employee completes an Employee
Injury Report and submits it to the medical personnel at the medical facility. If the injured
employee is not capable of completing this report then his supervisor will assist in
completing the report. The injured employee’s supervisor will submit a copy of the
Employee Injury Report to the Safety Manager.

The supervisor of the injured will conduct a preliminary investigation and complete a
Supervisor’s Incident Investigation Report as well as submit it to the Safety Manager within
3 hours of the occurrence. The supervisor will complete this report also for all other
incidents/accidents and submit the report to the Safety Manager within 3 hours of the
incident.

In the event of any accident resulting in a fatality, the safety Manager immediately notifies
the contractor safety manager and Manager of Projects.

Further notifications will be in accordance with the following requirements.

All incidents / accidents must be reported to Contractor Safety manager verbally within 3
hours of the occurrence.

A short written notification to Contractor Safety Manager within 8 hours with the
basic details of the incident / accident.

A complete accident investigation report with the Root Cause Analysis of the
accident/incident and the committee’s recommendations for preventative action(s) shall be
submitted to Contractor and Owner within 3 days after the incident occurred. Copies of all
relevant documents must be attached to support the report.

4. Investigating Team/Committee

The Investigative Team will include the following personnel:

 Chairman-Safety Manager
 Engineer, Supervisor
 Members - Other personnel familiar with the practices involved in the incident that can
contribute to its analysis and recommend action to prevent recurrence.
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 Contractor’s Safety will assist upon request and on serious incidents, i.e., lost time.

5. Investigation

5.1 General
The purpose of any accident investigation is to identify all possible contributing causes so
that future incidents, similar in nature, can be prevented and to determine all the facts
which may have a bearing on legal liability. Investigations should be directed toward fact-
finding, not fault finding.
The investigation should begin as soon as possible after the necessary notifications have
been accomplished.

5.2 Conducting the Investigation

a.) When possible, discuss the accident with the injured employee.
b.) Discuss the accident with other employees who may have seen the accident.
c.) Carefully consider the following points:
o What was the injured employee doing prior to, and at the time of, the accident?
o Was this in pursuit of his/her regular duties?
o Was the employee properly instructed as to the manner in which to perform his/her
duties?
o Did he/she do the work in accordance with instructions?
o Did any other employee or contractor contribute to this accident?
o Was the equipment or machinery which the injured employee was using in good
condition?
o Was it properly guarded?
o Was it suited for the purpose for which it was being used?
o Was ample and sufficiently lighted work space provided?
o Were proper housekeeping conditions maintained?
o How is the same type of work done by other employees?
o Is there a safer way in which this work could be done?
o Was the injured in good health when reporting for work on the day of the accident?

5.3 Witnesses
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a.) All personnel associated with the operation and other eye witnesses to the accident
shall be interviewed and written statements taken.

b.) The information obtained during these interviews must be limited to direct knowledge of
what was observed. Opinions and hearsay information do not represent factual
findings!

c.) Each individual interviewed should be requested to sign a statement of his or her
recorded sequence of events that lead up to and include the accident.

d.) The following information should be obtained from each individual interviewed:
 Name, employing contractor, employee number, address and occupation or trade.
 Date, time and place of interview.
 Where the person being interviewed was at the time of the accident.
 A complete narrative of what the witness knows of the accident.
 What operational activity or other events were taking place prior to and at the time of
the accident.
 What materials (lumber, concrete, steel, etc.), equipment (tools, cranes, scaffolding,
etc.) or conditions (weather, working environment, labor disputes, etc.) were involved.
This would also include all possible contributing factors, personal and physical, whether
they are directly or indirectly related to the accident.
 What facts may have caused the accident? Answers must be as objective as possible.
Include all unsafe conditions and/or unsafe acts.
 Was there a pre-existing known and/or reported unsafe condition or actions associated
with the accident. If so, when was it reported, to whom and was there any action taken
at that time.
 Upon conclusion of the interview, review the statement with the witness and attempt to
clear up possible discrepancies. The statement should then be dated, signed and
witnessed by a third party. A sample form of a witness statement is included at the end
of this section.

5.4 Evidence
e.) It is in the best interest of all parties that all physical evidence not be disturbed or
tampered with, regardless of the circumstances involved.

f.) All efforts must be made to secure the area of the accident as soon as possible after
the occurrence to prevent any alteration of the scene prior to the investigation.
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g.) If any equipment, tools and/or materials are involved with the accident, they shall, after
marking location, be removed from service and placed in safekeeping. If this proves to
be impractical, the area in which the accident occurred shall be cordoned off and
security personnel shall be posted to keep all unauthorized personnel out of the area.

h.) The secured area shall only be reopened upon approval from the Safety Manager.

5.5 Photographs, Video Recordings, Drawings and Diagrams

i.) Where applicable and with proper authorization, photographs may be taken of the
scene of the incident as well as any equipment involved in the incident. If possible,
sufficient photographs, and/or video recordings shall be taken as soon as possible after
the accident by the Safety Manager or designees, (if authorized), since conditions
rapidly change. Each photograph shall be properly labeled with the following
information:
o Description and location of principal item(s),
o Positions/directions in which the photographs were taken,
o Dates and time and,
o Name of photographer.

j.) The investigator should endeavor to provide a series of shots which supply a maximum
of useful information and which will enable the viewer to understand how the accident
occurred.

k.) Several photographs should be taken employing a general view. The camera should
be utilized clockwise until at least four general view photographs have been taken.

l.) A set of views should be selected to show the relationship of the accident to
surrounding structures or articles. This may be suggestive of action immediately
preceding the accident.

m.) As the scene is examined, various objects will appear to have relation to the injury.
Tools, blood stains and similar items should be photographed before they are moved or
cleaned up. Two (2) photographs are needed for a significant object, which is less than
300 mm in length. The first should be at close range to obtain a fairly large image of
the article. Also, the use of a ruler laid alongside of the object shows exact
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measurement of object. The second photograph should be taken with the camera
approximately 1.8 meters from object in order to bring the background in view and
show the object in perspective.

n.) Any contiguous areas, which may have been used by victim, should be considered part
of the scene of the accident. The nature of the accident will determine the extent to
which the environs need be photographed for a fuller understanding of the events that
lead to the accident.

o.) The camera should be carefully placed to provide a perspective, which is both normal
and informative. The incorrect selection of photographic angle often results in a
distorted and false impression of the scene. This must be avoided, as we want to
represent only factual information.

p.) It is sometimes desirable to illustrate the statement of a witness by means of a "posed"

photograph. In this way, the inadequacies of verbal testimony can be graphically
remedied. To accomplish a posed photograph, a person with the same general
physical appearance should be used. Naturally, he/she should be placed in the same
spot and positions as directed by the witness. Marks or pointers should be used to
clarify important aspects of the photograph. For example, chalk can be used to show
body position of victim. Prior to such a procedure, however, photographs should be
made of the untouched scene to obviate any objection to the photograph in court on
the grounds that it does not purport to show the original scene.

q.) Drawings and diagrams should be marked up and/or sketches prepared to indicate the
location of the accident. All measurements of time, distance, size, weight, etc., must
be accurate. In the event of unknowns (speed, distance, weight, etc.), every attempt
must be made to closely approximate the same with tables, formulas or calculations
which must be kept as part of the accident investigation.

5.6 Accident Report Format

r.) The investigative report shall be completed as soon as possible. An accurate, detailed
narrative description of the operation being performed at the time if the incident is of
extreme importance. It is important to remember that a minor miscalculation of
movement may have been the generating force that triggered the sequence of events,
which resulted in the accident.
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s.) Investigative reports should reveal the following:

o What happened?
o When did it happen?
o Where did it happen?
o Why did it happen?
o Who did it happen to?

t.) A sequence of all pertinent facts by the time of their occurrence should be embodied in
the report.
o Time - activity prior to accident.
o Time - occurrence.
o Times - emergency notification of first aid, safety, ambulance, etc.
o Times - arrival at scene of first aid team, ambulance, etc.
o Time - initial treatment or rescue efforts began.
o Time - arrival of ambulance at medical facility, medical treatment, surgery, etc.

5.7 Accident Investigation Quick Checklist

In case of a serious accident on the project, the following must be done:
1.) see that the injured are cared for
2.) protect other people and property
3.) have someone call the construction manager, site manager, safety manager, and
client.
4.) preserve the scene as it was after the accident
5.) make a visual walk through of the accident site
6.) obtain the identity of all people who might have information about the accident
7.) examine the evidence
8.) photograph all evidence
9.) make a diagram of the accident site
10.) interview and obtain statements from all witnesses
11.) prepare an accident report

5.8 News Media Release

If contacted by the news media concerning an accident, a "no comment" response should
be avoided. Should anyone receive any media inquiries, they should do the following:
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1.) Request a name, phone number, and name of the publication or industry affiliation
2.) If pressed for specific questions, simply apologize and explain that you are not the
person they should be talking to
3.) Inform the caller that a Project spokesperson will return their call immediately; and
4.) Call the Safety Manager and Owner’s Safety Manager with this information.

5.9 Summary
u.) At the conclusion of a major accident investigation, a meeting will be held at the work
site of the incident to assure the cause has been determined and proper corrective
action has been initiated.

v.) The following personnel will attend this meeting:

o Contractor Safety Manager
o Subcontractor’s Safety Manager
o Sub/Contractor Construction Manager / Coordinator
o Owner safety manager (optional)

w.) If all the facts surrounding an accident have been determined, it should not be difficult
to decide what action is necessary to prevent other employees with similar duties or
exposure to the same conditions from having the same type of accident.

5.10 Distribution of Reports

When the report is completed, distribution should be made in the following manner:

x.) The Contractor Safety Manager will send a completed copy to the Contractor
Construction Manager.
y.) The Contractor Construction Manager will review the report for thoroughness of the
investigation and for appropriate corrective action.
z.) The Contractor Construction Manager will make distribution to the Owner Safety
Department.
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Attachments

A Supervisor Incident Investigation Report

B Employees Report of Occupational Injuries/Illnesses
C Codes List
D Equipment Incident/Accident Report
E Formal Accident Investigation Report
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Attachment A) Supervisor Incident Investigation Report

Company Location/Area
Supervisor Date/Time

Injury Illness Near miss

Injured Name ID.BADGE#

Description of injury

Equipment/Property damage

Description of Incident

Investigation result

Witness Could injury have been prevented?

Activity at time of incident

Procedure Violation

Defective equipment/material

What management control or process weakness allowed this incident to occur and what is going to be done to
identify and correct this weakness

Recommendations

Signature Supervisor Date

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Attachment B) Employees report of Occupational Injury/Illness

Employees Report of Occupational Injury/Illness

Company Name Date
Accident Location Discipline
Employee Name ID No.
Home Address
(Street)
City/Country Telephone No.

Age Sex Marital Status No. Children

Date of Injury / Illness :* Time of Injury Illness:* Day of Week :

How Did The Incident Occur?

How Could The Injury / Illness Have Been Prevented?

Signature Date

To Be Completed By Physician/First Aid Attendant

Description of Injury / Illness*

Type of Treatment First Aid Doctor Hospital None

Description of First Aid Treatment (if doctor/Hospital, include all name(s), address(es), and Phone
no(s).):

Disabling Injury / Illness* Yes No Duration of Disability:

Analysis codeS
Nature of Body Part Cause* Unsafe Act Unsafe Condition
Injury/Illness* Yes Yes
No No
No. ___________ No. __________ No. __________ _____________ ________________
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Signature: Date:

Attachment C) Codes List

Type: Code:
CAUSE OF ACCIDENT Burn or Scald-Heat Or Cold Exposure
01 Chemicals
02 Contact With Hot Object
03 Burn Due To Temperature Extremes
04 Burn Due To Fire Or Flame
05 Burn Due To Steam/Hot Fluids
06 Dusts, Gases, Fumes Or Vapors
07 Burn Due To Welding Operations
08 Radiation Burn
09 Miscellaneous Burn Or Scald
CAUGHT IN OR BETWEEN 10 Caught in Machine/Machinery
12 Caught In/Bet Object Handled
13 Miscellaneous
CUT, PUNCTURE, SCRAPE INJURED BY 14 Cut Or Injured By Broken Glass
15 Hand Tool Injury (Non Powered)
18 Powered Hand Tool, Appliance
19 Misc. Cut/Punctures/Scrape/Injury
FALL OR SLIP INJURY 25 Fall/Slip From Different Level
26 Fall/Slip From Ladder/Scaffold
27 Slip From Liquid/Grease, Spill
29 Slip Or Fall From Same Level
30 Slipped - Did Not Fall
31 Miscellaneous Slip Or Fall
MOTOR VEHICLE 45 Collision With Another Vehicle
46 Collision With A Fixed Object
47 Crash Of Airplane
48 Vehicle Upset
50 Miscellaneous Motor Vehicle
STRAIN OR INJURED BY 17 Strain Or Injury By Jumping
53 Injury By Holding Or Carrying
54 Strain Or Injury By Lifting
55 Injury By Pushing Or Pulling
56 Strain Or Injury By Reaching
57 Injury By Using Tool/Machine
58 Miscellaneous Strain or Injury
STRIKING AGAINST OR STEPPING ON 65 Strike/Step On Moving Parts
66 Strike/Step On Object Lifted
67 Scraping/Cleaning Operation
68 Strike/Step On Stationary Obj.
69 Strike/Step On Sharp Object
70 Misc. Striking Against/Step On
STRUCK OR INJURY BY 75 Struck By Falling/ Flying Object
76 Struck By Hand Tool In Use
77 Struck By Motor Vehicle
78 Struck By Moving Machine Parts
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79 Struck: Object Lifted/Handled

80 Struck: Obj Handled By Others
81 Miscellaneous Struck or Inj. By
MISCELLANEOUS CODES 84 Contact With Electric Current
85 Animal Or Insect
86 Explosion Or Flare Back
87 Foreign Body In Eye
89 Robbery Or Criminal Assault
98 Cumulative (All Others)
99 Other
BODY PART 10 Multiple Head Injury
HEAD 11 Skull
12 Brain
13 Ear(s)
14 Eye(s)
15 Nose
16 Teeth
17 Mouth
18 Other Facial Soft Tissue
19 Facial Bones
NECK 20 Multiple Neck Injury
21 Cervical Vertebrae
22 Cervical Disc
23 Cervical Spinal Cord
24 Larynx
25 Neck Soft Tissue
26 Trachea
UPPER EXTREMITIES 30 Multiple Upper Extremities
31 Shoulder, Clavicle & Scapula
32 Elbow
33 Lower Arm
34 Wrist
35 Hand
36 Finger(s)
37 Thumb
TRUNK 40 Multiple Trunk
41 Upper Back Area: Thoracic Area
42 Lower Back Area: Lumber/Sacral
43 Disc
44 Chest
45 Sacrum & Coccyx
46 Pelvis
47 Spinal Cord (Back)
48 Internal Organs
49 Heart
LOWER BACK 50 Multiple Lower Extremities
51 Hip
52 Thigh
53 Knee
54 Lower Leg
55 Ankle
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56 Foot
57 Toe(s)
INTERNAL ORGANS 70 Liver
71 Respiratory System
72 Circulatory System
73 Nervous System
74 Reproductive System
75 Muscular System
76 Skeletal System
77 Digestive System
78 Immune System
79 Psyche System
84 Urinary Tract
85 Lymph System
86 Blood
87 Genitals
88 Rectum
MULTIPLE BODY PARTS 90 Multiple Body Parts
MISCELLANEOUS CODES 91 Broken Glasses
94 Shoulder
99 Unknown
NATURE OF INJURY Specific Injury
02 Amputation
03 Angina Pectoris
04 Bum
07 Concussion
10 Contusion
18 Crushing
19 Dislocation
20 Electric Shock
22 Enucleation (Removal Of Eye)
25 Foreign Body
28 Fracture
30 Freezing
31 Hearing Loss (Temporary Only)
32 Heat Prostration
34 Hernia
35 Infection
36 Inflammation
37 Allergic Reaction
38 Carpal Tunnel
39 Laceration
40 Myocardial Infraction (Heart Attack)
41 Coronary Oculus
42 Puncture
43 Muscle Spasm
45 Swelling
46 Rupture
47 Severance
48 Arthritis
49 Sprain
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50 Artherole Scle.
51 Cardiovascular
52 Strain
54 Asphyxiation
55 Vascular
58 Vision Loss
59 All Other
OCCUPATIONAL DISEASE OR CUMULATIVE 60 Dust Disease Noc (All Other)
INJURY 61 Asbestosis
62 Black Lung
63 Byssinosis
64 Silicosis
65 Respiratory Disorder (Gases, Fumes, Chemicals,
Etc.)
66 Poisoning: Chemicals
67 Poisoning: Metal
68 Dermatitis
69 Mental Disorder
70 Radiation
71 All Other Occupational Diseases
72 Loss Of Hearing
73 Contagious Disease
74 Cancer
76 Coron. Thrombosis
77 Internal Hemorrhage
78 Cerebral Hemorrhage
79 Brain Damage
80 All Other Cumulative Injuries
MISCELLANEOUS CODES 81 Death
82 Quadriplegic
83 Paraplegic
84 Conjunctivitis
85 Ligament
99 Unknown
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Attachment D) Equipment Incident/Accident Report

EQUIPMENT INCIDENT/ACCIDENT REPORT

Company Name Date & Time

Accident Location Discipline

Manufacturer

Description of Equipment Type Model

Equipment No.
Serial No.
Estimated Cost of Repairs:
Description of Damage:

Description of How The Incident/Accident Occurred (Why? What? Where? Etc.?)

Operator’s Name Responsible Supervisor

Reported By: Reported To

Equipment Leased From

Lessor Notified Contact Name Date Notified

Yes No
Lessor’s Recommended Action

Remarks

Submitted By: Date Submitted

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Attachment D: Formal Accident Investigation Report

FORMAL ACCIDENT INVESTIGATION REPORT (MANAGEMENT)

Project / Site Name: Date:

Exact Location of Accident: Date of Occurrence:

City: State: Time of Occurrence:

Supervisor’s Title:

Report Prepared By: Site Emergency

Plan in Place Yes No
Project Manager or Designee:

Describe How Indicent Occurred, Activity, Authority, Job Method, Etc.

Injured: Social Security No.

Address: City: State: Zip:

Nature of Injury / Illness:

Body Part: Source of Injury:

Previous Injuries

Activity At Time Of Accident

Name / Address Of Doctor

Name / Address of Hospital

Property Damage
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Model / Serial Number:

Nature of Damage

Source of Damage

ANALYSIS OF CAUSE:

Immediate Causes. What substandard acts and conditions contributed directly to this incident

What Personal Factors Were Basic Causes of This Incident? Explain.

Lack of Knowledge or Skill
Improper Motivation
Physical or Mental Problems
Inadequate Planning
Willful Deviation
What Job Factors Were Basic Causes of this Incident? Explain.
Inadequate Work Standards
Inadequate Design
Inadequate Maintenance
Abuse or Misuse
Inadequate Inspection
Inadequate Purchasing Standards
What are the Reasons for the Activity being out of control? Explain.
Inadequate Program
Inadequate Program Standards
Inadequate Compliance with Standards
Potential Loss if not Corrected:
Loss Severity Potential:
Major
Serious
Minor
Probability of Recurrence:
Frequent
Occasional
Seldom
Type of Incident:
Caught In
Caught Between
Struck By
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Fall Same Level

Exposure To
Caught On
Struck Against
Strain / Stress
Fall to Lower
Contact With
PREVENTION:
Action Plan: What has or should be done to prevent similar loss?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
RECOMMENDATIONS:
Recommendations for improvements or to prevent recurrence of accident. Transfer to action register.
Feedback on completion.
Recommendation one

Assigned to: Completed by:

Recommendation two

Assigned to: Completed by:

Recommendation three

Assigned to: Completed by:

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Investigation Report
Personal Protective Equipment Use:

Function Item or Required Available Used Needed Other

Model
Head Protection
Eye Protection
Respiratory Protection
Ear Protection
Body Restraint
Body Clothing
Foot Protection
Gloves
Fire / Heat Protection
Other
Influencing Factors: (C=Contributed; N=Not A Factor; P=Present But Not Significant)

Supervisory: C N P

Inadequate Training
Inadequate Instructions
Inadequate Planning
Task Overloading
Used Unqualified People
Allowed Insufficient Time
Inadequate Requested Equipment
Written Instructions Not Used
Proper Tools Not Provided
Lack Of Order
Inadequate Job Analysis
Inadequate Job Observation
Protective Equipment Not Provided
Communications:
No Instructions / Feedback
Misinterpretation
Disrupted
Noise Interference
Language Barrier
Used Only One Mode
Environmental:
Heat
Cold
Noise

Environmental (cont’d): C N P

Vibration
Pressure Loss / Change
Smoke Fumes
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Wind Draft / Air Blast

Acceleration / Deceleration
Weather
Psychological:
Human Design Factors
Perceptual Illusion
Perceptual Distortion
Habit Interference
Misinterpretation
Preoccupation
Distraction
Attention Fixation
Inattention
Boredom
Apprehension
Overconfidence
Excessive Motivation To Produce
Panic
Physiological:
Fatigue Chronic
Fatigue Acute (Temporary)
Toxic Poisoning
Hyperventilation
Drug or Medication
Alcohol
Hangover
Hypoglycemia (Low Blood Sugar)
Dizziness
Nausea
Other Illness:__________________________________________
Additional Notes
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Continuation Sheet
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DOC No ABG-707
PAGE No 25 of 26
PACKAGE “P” POWER PLANT
RAS AZ ZAWR POWER AND DESALINATION PLANT REV 0
DATE

Accident Incident Report

FORMAL ACCIDENT INVESTIGATION REPORT

(MANAGEMENT)

PROJECT / SITE NAME: DATE:

EXACT LOCATION OF ACCIDENT: DATE OF OCCURRENCE:

CITY: STATE: TIME OF OCCURRENCE:

SUPERVISOR’S TITLE:

REPORT PREPARED BY: SITE EMERGENCY

PLAN IN PLACE YES NO
PROJECT MANAGER OR DESIGNEE:

DESCRIBE HOW INDICENT OCCURRED, ACTIVITY, AUTHORITY, JOB METHOD, ETC.

DESC
RIPTI
ON

INJURED: SOCIAL SECURITY NO.

ADDRESS: CITY: STATE: ZIP:

NATURE OF INJURY / ILLNESS:

BODY PART: SOURCE OF INJURY:

PREVIOUS INJURIES

ACTIVITY AT TIME OF ACCIDENT

NAME / ADDRESS OF DOCTOR

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NAME / ADDRESS OF HOSPITAL

PROPERTY DAMAGE