Safety Incident Report

• Audit Number

• Report Date

  Date

• Project Manager

  Luc Gervais

  Jim Boyd

  Andrei Sarcovschi

  Jim Huff

• Job Name

• Location
  Address

• Weather

  Select Sunny Partly Sunny Cloudy Rain Light Rain Heavy Rain Snow Interior

  • Sunny
  • Partly Sunny
  • Cloudy
  • Rain
  • Light Rain
  • Heavy Rain
  • Snow
  • Interior

• Temperature

Project Name

• Project Name

  Select Nobleford Black Diamond Turner Valley

  • Nobleford
  • Black Diamond
  • Turner Valley

Project Manager

• Project Manager

  Select Randy McDonald Lloyd Alberts Dennis Melenka

  • Randy McDonald
  • Lloyd Alberts
  • Dennis Melenka

J2Link Group Project Manager

• J2Link Group Project Manager

  Select Luc Gervais Jim Boyd Andrei Sarcovschi Jim Huff

  • Luc Gervais
  • Jim Boyd
  • Andrei Sarcovschi
  • Jim Huff

On Site Manager

• On Site Manager

  Select Aaron Hamilton Mike Belise

  • Aaron Hamilton
  • Mike Belise

Incident Location

• Location

  Off

  On

• Incident Location

• Incident Description

  Off

  On

• Describe Incident

  Off

  On

• Type

  Select Equipment Failure Public Safety Personal Injuries Utility Damage Public Property Damage

  • Equipment Failure
  • Public Safety
  • Personal Injuries
  • Utility Damage
  • Public Property Damage

• Actions Required

• Corrective Actions

  Off

  On

• Measures put in place

  Off

  On

• Actions taken

  Stop Work

  Review Site for Safety Issues

  Review Safety Plans

  Tailgate Reviews

• Progress Made

• Safety Plan Changes

  Off

  On

• Men

  Off

  On

• Corrective Actions Major

  Change Safety Plans

  Remove Crew Members

  Change Tailgate Plan

  Suspend Contractors

• Progress Made

• Summary

  Off

  On

• Describe Measures to ensure Incident will not reoccur

  Off

  On

• # of Men

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Progress Made

• Safety

  Off

  On

• Foremen

  Off

  On

• Name

  Aaron Hamilton

  Mike Belise

• Safety issues

Daily Safety Checklist

• Have previous days hazards been addressed?

  Yes

  No

  N/A

• Is the area clear of new hazards?

  Yes

  No

  N/A

• Is all equipment in proper working condition?

  Safe

  At Risk

  N/A

• Have utilities been identified and located?

  Yes

  No

  N/A

• Are Subcontractors complying with safety standards?

  Yes

  No

  N/A

• Are there any outstanding events in the coming week ?

  Yes

  No

  N/A

• Facility Rep Informed- Date Required

• Was an Incident Report OSHA Form filled out today?

  Yes

  No

  N/A

• Details

Daily Activity Detail Log

Observation Report

Observation

• Observation Notes

• Schedule

• Safety

• Responsible Party/Parties

  Select Randy McDonald Lloyd Alberts Dennis Melenka

  • Randy McDonald
  • Lloyd Alberts
  • Dennis Melenka

• Party Contacted?

  Off

  On

• Informational

• Photo

  Media

• Description of Photo(s)

Project Progress Information

• Daily Update Pictures

  Media

• Notes

Daily Report Authentication

• Litewave sign-off

  Sign