MBJ3 Safety Sign In log

• Document No.

• Meeting Type

  Weekly Sub Safety Committee Terminal Walk

  Monthly Sub Safety Committe Meeting

  Accident/Incident Review

  Other

• Purpose of the Meeting

• Conducted on

  Date

• PREPARED BY

  Select Cleve Magers Juan Lopez John Cornelius Bryce Powers Phillip Baker Robert Arredondo Other

  • Cleve Magers
  • Juan Lopez
  • John Cornelius
  • Bryce Powers
  • Phillip Baker
  • Robert Arredondo
  • Other

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• Are there more attendees?

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SAFETY ITEMS DISCUSSED

• Was this a Weekly Sub Safety Committee Terminal Walk?

  Off

  On

• Please have each member or team(s) complete at least one MBJ3 Bi-Weekly Jobsite Inspection form.

• Was this a Monthly Sub Safety Committe Meeting?

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  On

• Topic #1:

• Topic leader

  Select Cleve Magers Juan Lopez John Cornelius Bryce Powers Phillip Baker Robert Arredondo Other

  • Cleve Magers
  • Juan Lopez
  • John Cornelius
  • Bryce Powers
  • Phillip Baker
  • Robert Arredondo
  • Other

• Name of leader

• Topic #2:

• Topic leader

  Select Cleve Magers Juan Lopez John Cornelius Bryce Powers Phillip Baker Robert Arredondo Other

  • Cleve Magers
  • Juan Lopez
  • John Cornelius
  • Bryce Powers
  • Phillip Baker
  • Robert Arredondo
  • Other

• Name of leader

• Topic #3:

• Topic leader

  Select Cleve Magers Juan Lopez John Cornelius Bryce Powers Phillip Baker Robert Arredondo Other

  • Cleve Magers
  • Juan Lopez
  • John Cornelius
  • Bryce Powers
  • Phillip Baker
  • Robert Arredondo
  • Other

• Name of leader

• We're additional topics discussed?

  Off

  On

• Topic #4:

• Topic leader

  Select Cleve Magers Juan Lopez John Cornelius Bryce Powers Phillip Baker Robert Arredondo Other

  • Cleve Magers
  • Juan Lopez
  • John Cornelius
  • Bryce Powers
  • Phillip Baker
  • Robert Arredondo
  • Other

• Name of leader

• Topic #5:

• Topic leader

  Select Cleve Magers Juan Lopez John Cornelius Bryce Powers Phillip Baker Robert Arredondo Other

  • Cleve Magers
  • Juan Lopez
  • John Cornelius
  • Bryce Powers
  • Phillip Baker
  • Robert Arredondo
  • Other

• Name of leader

• Was this a Accident/Incident Review?

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  On

• What type of accident or incident?

  Near Miss

  Injury

  Property Damage

  Special Case

• Date and time of accident/incident

  Date

• Name and ROCIP badge number of the affected employee

• Affected employee Job title (position)

• Worker status

  Full Time

  Part Time

  Temporary

  N/A

• What is the temporary agency name?

• Explain why your answer was N/A.

• Highest level of treatment received.

  No Treatment

  First Aid

  Sent to Clinic or Hospital

• Company name for affected worker

• Specific location of accident/incident, for example: Column line 70A-C, Entry vestibule E17, etc.).

• Were there any witnesses?

  Yes 1

  Yes 2

  Yes 3

  No

• Witness #1's Name

• Was a statement taken?

  Yes

  No

  N/A

• Witness #1's Name

• Was a statement taken?

  Yes

  No

  N/A

• Witness #2's Name

• Was a statement taken?

  Yes

  No

  N/A

• Witness #1's Name

• Was a statement taken?

  Yes

  No

  N/A

• Witness #2's Name

• Was a statement taken?

  Yes

  No

  N/A

• Witness #3's Name

• Was a statement taken?

  Yes

  No

  N/A

• What directly happened to cause the Accident/incident? Choose all that apply

  Select Work area and site specific related Employee related Equipment related PPE related Assistance related Management factors Other

  • Work area and site specific related
  • Employee related
  • Equipment related
  • PPE related
  • Assistance related
  • Management factors
  • Other

• Choose all that apply

  Select PPE not worn PPE not adequate for the task PPE failure Proper clothing not worn Other

  • PPE not worn
  • PPE not adequate for the task
  • PPE failure
  • Proper clothing not worn
  • Other

• Explain "Other" response

• Choose all that apply

  Select Task was too difficuly to perform alone Assisstive devices not used Other

  • Task was too difficuly to perform alone
  • Assisstive devices not used
  • Other

• Explain "Other" response

• Choose all that apply

  Select Training not provided Poor communication regarding duty expectations Improper employee assignment Safety inspection failed or not provided Inadequate preventative maintenance Proper tools or equipment not provided Productivity given priority over safety failure to recognize potential hazards Other

  • Training not provided
  • Poor communication regarding duty expectations
  • Improper employee assignment
  • Safety inspection failed or not provided
  • Inadequate preventative maintenance
  • Proper tools or equipment not provided
  • Productivity given priority over safety
  • failure to recognize potential hazards
  • Other

• Explain "Other" response

• Explain "Other" response

• Choose all that apply

  Select Work area not set up properly Adverse environment conditions Proximity to other trade work Housekeeping issues Animal/insect attack Poisonous vegetation Equipment failure Proper equipment not used Equipment was improperly used other Other

  • Work area not set up properly
  • Adverse environment conditions
  • Proximity to other trade work
  • Housekeeping issues
  • Animal/insect attack
  • Poisonous vegetation
  • Equipment failure
  • Proper equipment not used
  • Equipment was improperly used
  • other
  • Other

• Explain "Other" response

• Describe the injury or illness, parts of body affected, and object/substance that directly injured or made affected employee ill.

• Describe the corrective action taken

• Explain the special case

• Explain in detail what property was damaged

• Rate potential severity for injury based on the sequence of events for this incident.

  Select Worst case is first aide Worst case is lost time High potential for fatality

  • Worst case is first aide
  • Worst case is lost time
  • High potential for fatality

• Explain the near miss in detail. Including if a citation was written, and who wrote the citation.

• Rate potential severity for injury based on the sequence of events for this incident.

  Worst case is first aide

  Worst case is lost time

  High potential for fatality

• Was this another type of meeting?

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  On

• Describe the type and content of the meeting.