Environmental Engineering Reference
In-Depth Information
PrIncIPAl Person dAtA
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NAME:..______________________________ .SOCIAL.SECURITY.NO.:.._______________________
(LAST ONLY) (LAST FOUR DIGITS)
Company.Number:..____________________________________________________________________
DATE.OF.BIRTH:. SEX:._________. HEIGHT:._________.(IN.). WEIGHT:._________.(LB)
_________/_________/_________. (from.records). (from.records)
JOB.TITLE.OR.CLASSIFICATION:.._____________________________________________________
EXPERIENCE:._______________________________________________________________________
Total:._________.Years._________.Mos.._________.With.Company:._________.Years._________.Mos.._________
At.This.Operation:.________.Years.________.Mos.._______.In.Job.Classiication:.________.Years.Mos..________.
In.Task.in.Which.Accident.Occurred:._________.Years._________.Mos.._________.
Physical.Impairments.or.Limitations:.(describe):..____________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Eye.Sight:. Left.Eye.20/._________. Right.Eye.20/._________.
Primary.&.Secondary.Education.(Last.Year.Completed):..______________________________________
College.(Last.Year.Completed):..__________________________________________________________
Technical/Vocational.Schooling:.______________________________________.Years._________.Months._________.
Vocational.Area(s):..____________________________________________________________________
Accident.History.Past.Five.Years.(All.Employees):.. __________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Safety.Violation.History.(Last.Two.Years):.._________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Disciplinary.Actions.Last.Two.Years:.. _____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Hours.Worked.(Here.&.Elsewhere).in.48.Prior.to.Accident:._________.Hours
120.Prior.to.Accident:._________.Hours
Sleep.in.Last.48.Hours:._________.Hours.
Time.Since.Last.Slept:._________.Hours
