Information
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Audit Title
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Client / Site
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Conducted on
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Prepared by
Notification
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CH2M HILL Project Manager Notified
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PM Name
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Notified By
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Date and Time Notified
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CH2M HILL Regional HSM Notified
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Regional HSM Name
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Notified By
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Date and Time Notified
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CH2M HILL Site HSM Notified
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Site HSM Name
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Notified By
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Date and Time Notified
Employer Information
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Business Market
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Company Name
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Employee Name
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Contact Name
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Contact Number
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Project Name
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CH2M HILL Project Number
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Project Location
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Task Location
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Job Assignment
Incident Specific Information
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Type of Incident
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Equipment Malfunction
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Activity was a Routine Task
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Activity Type
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Injury Type
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Part of Body Injured
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Date of Initial Treatment/Diagnosis
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Type of Treatment
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Number of days doctor required employee to be off work
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Number of days doctor restricted employee's work activity
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Physician Information
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Hospital Information
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Specific activity the employee was engaged in when the incident occurred
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All equipment, materials or chemicals the employee was using when the incident occurred
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Describe how this incident occurred and how it may have been prevented
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Contributing Factors
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Date and Time Incident Occurred
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Address where the incident occurred
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Location of Incident
Employee Information
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Name
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Duration of employment by company
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Date of site specific safety orientation
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Statement
Witness Information
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Name
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Statement
Additional Information
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Additional Notes
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