Environmental Engineering Reference
In-Depth Information
ImmedIAte suPervIsor dAtA
NAME:.._____________________________________________________________________________
(FIRST)
(MIDDLE)
(LAST)
EXPERIENCE.AS.A.SUPERVISOR:._________.MONTHS
TOTAL.EXPERIENCE:._________.MONTHS
heAlth And sAFety courses/trAInIng receIved
dAte:
TIME.LAST.PRESENT.AT.SCENE:.. _____________________________________________________
MINUTES.PRIOR.TO.ACCIDENT:..______________________________________________________
WERE.INSTRUCTIONS.RELATED.TO.ACCIDENT.GIVEN?.
□
.YES.
□
.NO
WHAT.INSTRUCTIONS.WERE.ISSUED?..________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
TIME.OF.LAST.CONTACT.WITH.PRINCIPAL.IN.ACCIDENT:..______________________________
MINUTES.PRIOR.TO.ACCIDENT:..______________________________________________________
WHERE,.IF.NOT.AT.SCENE:.. __________________________________________________________
WAS.SUPERVISOR.AWARE.OF.UNSAFE.PRACTICES.OR.CONDITIONS?
□
.YES.
□
.NO
WHAT.WARNINGS.WERE.GIVEN.ABOUT.UNSAFE.PRACTICES.OR.CONDITIONS?. __________
____________________________________________________________________________________
DID.SOMEONE.OTHER.THAN.THE.FOREMAN/SUPERVISOR.DIRECT.WORK.OF.THE.
PRINCIPAL.IN.ACCIDENT?
□
.YES.
□
.NO. NAME:.. ________________________ .TITLE:..__________________________
HIS/HER.EXPERIENCE.IN.TASK.IN.WHICH.PRINCIPAL.WAS.INJURED:._________.MONTHS
WHAT.DIRECTION.DID.HE/SHE.GIVE.VICTIM?. _________________________________________
