Summit Utililities, Inc. Incident Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Type of incident (Select at least one box below)

• Injury / Illness

• Environment / Permit Issue

• Property Damage

• Near Miss

• Spill / Release

• Other - Enter specific information below

• If the incident resulted in an injury list the exact address here

• Include photos of the injury only with the employees permission here

  Media

General Information (Complete for all incident types)

• Preparers Name:

• Enter date of report here

  Date

• Enter date and time of the incident here

  Date

Verbal Notification (Complete for all incident types)

• List SUI Managers Name here

• Enter date and time SUI Manager was notified here

  Date

Type of activity that was being performed that resulted in the incident

• Asbestos Work

• Confined Space

• Construction Management - Hazardous Waste

• Construction Management - Non-Hazardous Waste

• Demolition

• Drilling - Hazardous Waste

• Drilling Non - Hazardous Waste

• Drum Handling

• Electrical Work

• Excavation Trench - Hazardous Waste

• Excavation Trench - Non - Hazardous Waste

• Facility Walk Through

• General Office Work

• Keyboard Work

• Lead Abatement

• Motor Vehicle Operation

• Moving Heavy Object

• Process Safety Management

• Tunneling

• Welding

• Working in Roadways

• Meter Set

• Working from Heights

• Other

• Specify other information here

Location of Incident (Select one from the boxes below)

• Include photographs of the incident here

  Media

• Company Premisis

• Enter Location Here

• Enter the Field - Project / Site Name below

• Enter Location Here

• In Transit - Traveling From - Traveling to

• Enter Locations Here

• At Home

• Other - List Address Below

Incident Investigation (Complete for all incident types)

The Employee States (The statement below is to be completed by the employee)

• Describe the incident ( Provide a full description of the incident and how it occurred)

• Task Location

• Job / Task Assignment

• Specify activity the employee was engaged in when the incident occurred

• List all equipment, materials, or chemicals the employee was using when the incident occurred

• Was the activity a routine task

  Yes

  No

  N/A

• Equipment Malfunction

  Yes

  No

  N/A

• Was the injury a result of a safety violation

  Yes

  No

  N/A

• Was safety equipment provided

  Yes

  No

  N/A

• Is video or photographic evidence available

  Yes

  No

  N/A

• Enter video or photos here

  Media

Root Causes and Contributing Factors

• Investigate, identify, evaluate any information leading to the incident here

• Describe how you may have prevented this injury

Witnesses (Complete for all incident types)

• Witness Information (First Witness)

• Name

• Address

• City

• Zip Code

• Phone Number

• This space is designed for the witness's written statement

• Witness information (Second Witness)

• Name

• Address

• City

• Zip Code

• Phone Number

• This space is designed for the witness's s written statement

Property Damage (Complete for all incident types)

• Property Damaged

• Property Owner

• Damage Description

• Estimated Amount of Damage ($)

• Enter photos of damaged property here

  Media

Spill or Release (Complete for Spill / Release incidents only)

• Substance (attach MSDS)

• Estimate Quanity

• Facility Name

• Facility Address

• Zip Code

• Phone Number

• Spill release from

• Spill release to

• Did the spill move off the property from where the work was being performed

  Yes

  No

  N/A

Environmental / Permit Issue ( Complete for Environmental / Permit Issue Incidents Only)

• Describe Environmental or Permit Issue

• Permitted Level or Criteria (e.g., discharge limit)

• Permit Name and Number (e.g., NPDES No. ST1234):

• Substance and Estimated Quanity

• Duration of Permitted Exceedence

Injury Information ( Complete for injury / illness incidents only)

If SUI Companies employee injured

• Employee Name

• Employees date of birth

• Employees address

• City

• Zip Code

• Employees phone number

If SUI Companies Subcontractor employee injured

• Employee Name

• Employee Phone Number

• Company

• Subcontractor Contact

• Subcontractor Contact Phone Number

Injury Type

• Allergic Reaction

• Amputation

• Asphyxia

• Bruise / Contusion / Abrasion

• Burn (Chemical)

• Burn / Scald / Heat

• Cancer

• Carpal Tunnel

• Contusion

• Cut / Laceration

• Dermatitis

• Discoloration

• Electric Shock

• Foreign Body in eye

• Fracture

• Freezing / Frost Bite

• Headache

• Hearing Loss

• Hearing Loss

• Heat Exhaustion

• Hernia

• Infection

• Irritation to eye

• Ligament Damage

• Muscle Spasams

• Poisoning (Systemic)

• Puncture

• Radiation Effects

• Strain / Sprain

• Tendonitis

• Wrist Pain

Part of Body Injured

• Rate level of pain

• If body part effected is left or right (specify here)

• Abdomen

• Ankle (S)

• Arms (Multiple)

• Back

• Blood

• Body System

• Buttocks

• Chest / Ribs

• Ear (s)

• Elbow (S)

• Eye (S)

• Face

• Finger (S)

• Foot / Feet

• Hand (S)

• Head

• Hip (S)

• Kidney

• Knee (S)

• Leg (S)

• Liver

• Lower (arms)

• Lower (legs)

• Lung

• Mind

• Multiple / (Specify)

• Neck

• Nervous System

• Nose

• Other / (Specify)

• Reproductive System

• Shoulder (S)

• Throat

• Toe (S)

• Upper (Arms)

• Upper (legs)

• Wrist (S)

Nature of Injury

• Absorption

• Bite / Sting / Scratch

• Cardio-Vascular / Respiratory System Failure

• Caught in or Between

• Fall (From Elevation)

• Fall ( Same Level)

• Ingestion

• Inhalation

• Lifting

• Mental Stress

• Motor Vehicle Accident

• Multiple ( Specify)

• Other ( Specify)

• Overexertion

• Repeated Motion / Pressure

• Rubbed / Abraded

• Shock

• Struck Against

• Struck By

• Work Place Violence

• Initial Diagnosis

• (Enter Treatment Date Below)

The following information must be completed for Workers Compensation purposes

• Initial treatment none

• Minor on - site

• Clinic / Hospital

• Emergency Room

• Hospital > 24 hours

• Was the employee hospitalized over - night as an in - patient

• List the start of shift time for the injured employees date of injury here

  Date

• Application of bandages

• Cold / Heat Compression / Multiple Treatment

• Cold / Heat Compression / One Treatment

• First Degree Burn Treatment

• Heat Therapy / Multiple Treatment

• Multiple (Specify)

• Heat Therapy / One Treatment

• Non - Prescription medicine

• Observation

• Other (Specify Below)

• Prescription - Multiple Dose

• Prescription - Single Dose

• Removal of foreign bodies

• Skin Removal

• Soaking Therapy - Multiple Treatment

• Soaking Therapy - One Treatment

• Stitches / Sutures

• Tetanus

• Treatment for infection

• Treatment of 2cd / 3rd degree burns

• Use of antiseptics - multiple treatments

• Use of antiseptics - single treatment

• Whirlpool bath therapy / multiple treatments

• Whirlpool bath therapy - single treatment

• X - Rays negative

• X - Rays positive / treatment of fracture

Physician Information

• Name

• Address

• City

• Zip Code

• Phone Number

Hospital Information

• Name

• Address

• City

• Zip Code

• Phone Number

Date Reported to Corporate

• Select date

  Date

Additional Comments

• Managers Signature

  Sign

• Employees Signature

  Sign