AGREEMENT between BROWARD COUNTY and Cummings ...

Exhibit 2
Page 194 of 379
INCIDENT/ ACCIDENT INVESTIGATION FORM Report #
Contractor Name:
Contract Number:
Employee:
Job Title:
Social Security #__ __ __ - __ __ - __ __ __ __
Date of Injury:_______________________________________________ Time:__________________am pm
Time & Date Reported _____________________________________________________am
Location of Incident:
to on site Medical:
pm
Employee Supervisor:
Type of Injury:
Body Part(s) Affected:
Disposition:
Employee Not Sent To Dr. Yes No Employee Refused Treatment
Sent To:
Yes No Project Safety Notified
Emergency Room
Personal Physician Yes No Project Security Notified
Onsite First Aid Station
Time: ________ Person Notified:_________________________________________________________
Time: _____________ Person Notified:____________________________________________________
Other_________________ Lost Time Projected Time Out:________________________________________________________
______________________
Lost Time - Restricted Duty Projected Time Out:________________________________________________________
____________________
Medical Recordable
Name & Address of medical provider:____________________________________________________________________________________________________
Attending Nurse:_____________________________________________________________________________________________________________________
Describe In Detail What Employee Was Doing at the Time of Accident
Witnesses:
Circle Numbers Identifying Contributing Factors:
1. Absent/Improper Guarding
2. Defective Equipment
3. Weather/Temperature
4. Inappropriate Personal Protective Equipment
5. Inadequate Housekeeping
6. Slippery/Uneven Walking Surface
7. Improper Storage or Placement of Materials
8. Inadequate Ventilation
9. Inadequate Lighting or Noise Control
10. Improper Layout of Area
11. Insect/Animals in Work Area
12. No Unsafe Condition Identified
13. Other:__________________________________________________
Describe Contributing Factors:
14. Operating Without Authority
15. Improper Use of Equipment
16. Inadequate Procedures
17. Use of Defective Equipment/Tools
18. PPE Not Used
19. Inadequate Training
20. Improper Position or Posture
21. Horseplay
22. Altercation
23. No Unsafe Act Identified
24. Other:__________________________________________________________
25. Other:__________________________________________________________
26. Other:________________________________________
What actions are being taken to prevent recurrence (Use additional paper if necessary)
Was SPA developed for task performed at time of accident Yes No (If yes, attach copy to this form.)
Yes No did you speak with the employee regarding this incident
Yes No Has employee returned to work
Yes No Were statements taken Yes
If not, Last Day Worked:___________ Terminated or laid off___________
No Was employee aware of impending layoff/termination
Investigation team members:
Reviewed by:
Supervisor
Contractor Safety Representative/Date
Project Safety Manager/Date
Date of Investigation
H