Bonus Program- CRM Impact form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location of event

• Your department

  Select Maintenance Mine Ore process Ancillary Mill Tech Services Safety bonus contributions Other (please comment)

  • Maintenance
  • Mine
  • Ore process
  • Ancillary
  • Mill
  • Tech Services
  • Safety bonus contributions
  • Other (please comment)

• Which Maint group

  Select Fixed Electrical Mobile

  • Fixed
  • Electrical
  • Mobile

• Which group

  Select Dewatering Dispatch IT Operations

  • Dewatering
  • Dispatch
  • IT
  • Operations

• Which group

  Select Met lab Pads Plants Refinery Security

  • Met lab
  • Pads
  • Plants
  • Refinery
  • Security

• Which group

  Select General store Golf course Day care Hadley Maintenance Warehouse/Purchasing Clinic

  • General store
  • Golf course
  • Day care
  • Hadley Maintenance
  • Warehouse/Purchasing
  • Clinic

• Which group

  Select Accounting HR CI Management Safety

  • Accounting
  • HR
  • CI
  • Management
  • Safety

• Which group

  Select Environmental Assay lab Projects Survey Sampling Geotech Hydrology Geology

  • Environmental
  • Assay lab
  • Projects
  • Survey
  • Sampling
  • Geotech
  • Hydrology
  • Geology

• Was equipment involved

  Yes

  No

• Equipment type and numbers

• How many days into rotation

  Select 1 2 3 4 5 6 7 Overtime Extra shift

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • Overtime
  • Extra shift

• Shift

  Days

  Nights

• What part of shift did the Incident occur in

  First third of shift

  Middle third of shift

  Last third of shift

• Which Critical Risk would this be classified under?

  Select Cable Handling Permit to work programs Working around Conveyor belts Haul truck and small vehicle interactions Fueling Equipment Chemical Handling Fatigue Braking systems on Mid duty vehicles Shovel swing radius Heavy equipment operation Working on pressurized systems Equipment fires Working around highwalls Energy isolation Other (please comment)

  • Cable Handling
  • Permit to work programs
  • Working around Conveyor belts
  • Haul truck and small vehicle interactions
  • Fueling Equipment
  • Chemical Handling
  • Fatigue
  • Braking systems on Mid duty vehicles
  • Shovel swing radius
  • Heavy equipment operation
  • Working on pressurized systems
  • Equipment fires
  • Working around highwalls
  • Energy isolation
  • Other (please comment)

• Select the PTW program

  Select Working at heights Hot work Trenching and excavation Lifting/ Rigging/Towing Confined space

  • Working at heights
  • Hot work
  • Trenching and excavation
  • Lifting/ Rigging/Towing
  • Confined space

• Select type of energy

  Select Lock out, Tag out, Try out (LOTOTO) Live Testing Stored energy/pressure Other (please comment)

  • Lock out, Tag out, Try out (LOTOTO)
  • Live Testing
  • Stored energy/pressure
  • Other (please comment)

Critical Risk- incident

• Please select classification

  Select Critical risk incident with no injury Critical risk incident with first aid treatment Critical risk incident with Medical treatment

  • Critical risk incident with no injury
  • Critical risk incident with first aid treatment
  • Critical risk incident with Medical treatment

• Event Type

  Select Near miss Contact (person) Contact (property, equipment) Other (please comment)

  • Near miss
  • Contact (person)
  • Contact (property, equipment)
  • Other (please comment)

• Complete description

• Photo(s) of incident

  Media

• Immediate action(s) taken

  Select Reported to supervisor/management Shut the area/task down Added controls Other (please comment)

  • Reported to supervisor/management
  • Shut the area/task down
  • Added controls
  • Other (please comment)

• Reported to who

• What controls

  Select Elimination (Complete removal of hazard to worker) Substitution (Replace a hazard with something less hazardous) Engineering (Guards, alarms, reduce exposure, modify work) Administrative (Training, policies etc.) PPE (gloves, hearing protection etc. )

  • Elimination (Complete removal of hazard to worker)
  • Substitution (Replace a hazard with something less hazardous)
  • Engineering (Guards, alarms, reduce exposure, modify work)
  • Administrative (Training, policies etc.)
  • PPE (gloves, hearing protection etc. )

• What controls were added

• Potential actions (long term)

• Notify Committee

  Yes

• Incident Loss

  Select Injury (First aid)

  • Injury (First aid)

• Body part effected

• FAST team member

• Incident Type

  Select Struck against (running or bumping into) Struck by Fall from elevation to lower level Fall on same level Caught in (pinch point) Caught on (snagged, hung up) Caught between or under Contact with (electricity, heat, cold, chemical, toxic) Abnormal operation Product contamination Overstress, overpressure Equipment failure

  • Struck against (running or bumping into)
  • Struck by
  • Fall from elevation to lower level
  • Fall on same level
  • Caught in (pinch point)
  • Caught on (snagged, hung up)
  • Caught between or under
  • Contact with (electricity, heat, cold, chemical, toxic)
  • Abnormal operation
  • Product contamination
  • Overstress, overpressure
  • Equipment failure

• Photo(s) of incident

  Media

• Complete description

• Immediate action(s) taken

  Select Reported to supervisor/management Shut the area/task down Added controls Other (please comment)

  • Reported to supervisor/management
  • Shut the area/task down
  • Added controls
  • Other (please comment)

• Reported to who

• What controls

  Select Elimination (Complete removal of hazard to worker) Substitution (Replace a hazard with something less hazardous) Engineering (Guards, alarms, reduce exposure, modify work) Administrative (Training, policies etc.) PPE (gloves, hearing protection etc. )

  • Elimination (Complete removal of hazard to worker)
  • Substitution (Replace a hazard with something less hazardous)
  • Engineering (Guards, alarms, reduce exposure, modify work)
  • Administrative (Training, policies etc.)
  • PPE (gloves, hearing protection etc. )

• Comment required

• Potential actions (long term)

• Incident Loss

  Select Medical Injury Fatal Catastrophic failure

  • Medical Injury
  • Fatal
  • Catastrophic failure

• Body part effected

• Incident Type

  Select Struck against (running or bumping into) Struck by Fall from elevation to lower level Fall on same level Caught in (pinch point) Caught on (snagged, hung up) Caught between or under Contact with (electricity, heat, cold, chemical, toxic) Abnormal operation Product contamination Overstress, overpressure Equipment failure

  • Struck against (running or bumping into)
  • Struck by
  • Fall from elevation to lower level
  • Fall on same level
  • Caught in (pinch point)
  • Caught on (snagged, hung up)
  • Caught between or under
  • Contact with (electricity, heat, cold, chemical, toxic)
  • Abnormal operation
  • Product contamination
  • Overstress, overpressure
  • Equipment failure

• Photo(s) of incident

  Media

• Complete description

• Immediate action(s) taken

  Select Reported to supervisor/management Shut the area/task down Added controls Other (please comment)

  • Reported to supervisor/management
  • Shut the area/task down
  • Added controls
  • Other (please comment)

• Reported to who

• What controls

  Select Elimination (Complete removal of hazard to worker) Substitution (Replace a hazard with something less hazardous) Engineering (Guards, alarms, reduce exposure, modify work) Administrative (Training, policies etc.) PPE (gloves, hearing protection etc. )

  • Elimination (Complete removal of hazard to worker)
  • Substitution (Replace a hazard with something less hazardous)
  • Engineering (Guards, alarms, reduce exposure, modify work)
  • Administrative (Training, policies etc.)
  • PPE (gloves, hearing protection etc. )

• What controls were added

• Potential actions (long term)