Instructions for Completing the Line Organization Accident/Incident
Investigation Report Form

The following provides guidance for completing the Line Organization
Accident/Incident Investigation Report form. This form is intended to
provide a means of collecting data for all types of events occurring at
BNL from illness and injury to property and vehicle damage to include
those involving non-employees, such as visitors, contractors, etc.. It
is divided into two parts. The first part is mandatory and the second
part is intended for use by those interested in carrying the
investigation through to the event's root causes, ameliorating the
condition and providing for other information. If the section is not
applicable, draw a line through it or check the box if provided.

[Part 1: This part must be completed for all investigations]{.underline}

Part 1, Page 3: Case Number: Leave this number blank, it will be filled
in by personnel responsible for OSHA Recordkeeping.

Section A: This is to identify individuals involved in the event, their
occupation, line organization and supervisors. Space is provided for
more than one individual. The first named individual is the victim, or
subject about whom this investigation is proceeding. If this is an
incident involving more than one victim, please provide a completed
investigation for each. If others identified are witnesses, please
indicate that by placing a "W" next to the name.

Name: The first name listed should be that of the injured/ill
individual. Please do not use nicknames.

Occupation: If you know the person's official job title, please use
same.

Hospital: If the individual was transported to a hospital, please
indicate which one.

Life #: Please use Life Numbers for BNL employees. If it is not a BNL
employee, please use the Social Security Number or other identifier.

Telephone #: Extension at BNL through which the employee is reachable if
the need arises.

Line Organization: If a BNL employee, use the Lab organization
(Department or Division). If it is a contractor, use the contractor's
employer.

Supervisor: Please provide the name of the immediate BNL supervisor, or
contractor's supervisor.

Section B: Please indicate by a check mark in front of the
classification listed that which applies. If none apply then use other.
If you don't know, leave it blank.

Section C: Please indicate the date and time of the event on the first
line. The date the employee notified the BNL Line organization, or non
BNL employee notified his/her organization follows on the next line.
Please be as specific as possible about where the event occurred.

Please place check marks as appropriate in the rest of this section.
NOTE: Type C Investigation is for recordable injuries and requires
completion of all applicable sections of the report.

Section D: This section is only pertaining to non-BNL personnel.

Section E: Place check marks in the box in front of each item relating
to this for injury/illness only. If you do not know the answer, contact
Safety Engineering or your ESH Coordinator. (This section is similar to
the front page of the CAIRS report.)

Section F: This section applies only to non-illness/injury events and is
intended for use in reporting DOE property/DOE vehicle damage for the
DOE CAIRS reporting process, and or losses from radiological or
environmental events.

Section G: Indicate who notified Line Management of this injury,
including date and time, and who was notified.

Part 1, Page 4: [REQUIRED INVESTIGATION INFORMATION]{.underline}

Section H: Indicate what the person was doing at the time of the event,
the purpose of the work, what equipment was used and where it was being
done. Indicate also how often the task is performed and how often this
individual performs the task.

Section I: Just check yes or no.

Section J: Tell what happened, how it happened and the severity of the
injury or damage if known.

Section K: Request the diagnosis from OMC staff and enter it here.

Section L: Has been changed to section M. The new Section L is to
identify the body part injured.

Section M:: The old section M has been moved to Part 2, G. If the source
of the diagnosis is a non-BNL practitioner, indicate the name
here...also if you know that medical treatment beyond first aid is being
provided, list the treating practitioner here. You must provide the name
of the hospital only if the employee is admitted overnight.

Section N: Signature block at the end of Part 1 is for first aid cases
or for near misses only. If the case meets the criteria for
recordability, skip this section and move on to Part 2.

Part 2, Page 5: [REQUIRED FOR ALL CASES MEETING THE CRITERIA FOR
RECORDABILITY Complete only those sections which apply. You may draw a
line through those sections which do not apply.]{.underline}

Section A: Place a check mark in the box provided in front of those
surfaces and conditions that apply.

Section B: Complete this section only if the event was outdoors or if
weather somehow contributed to the event causality.

Section C: If this event involved tools, machines or equipment, place a
check mark in the space provided in front of the item and then identify
the tool, machine or equipment (e.g., \[x\] Non-powered Hand Tool
...hammer). If machines or other equipment are involved, indicate if
they are part of a Preventive Maintenance Program and if Lockout/Tagout
was applicable.

Section D: This box addresses miscellaneous items that are usually
peripheral to accidents, incidents and injuries, but may have some
contributing impact to the event. Please check only those items that
apply.

Section E: This section only applies to events that involved the use of
a vehicle. Please check only those events that apply.

Section F: [Completion of this section is required for all Type C
Investigations.]{.underline} Please place a mark in those boxes that
identify those hazards that apply.

Section G: [Completion of this section is required for all Type C
Investigations.]{.underline} There may be no right or wrong answer here.
It may be necessary for you to seek assistance from your ESH
Coordinator, or the Safety Engineering Group to complete this portion.
If you are unable to determine the causality, use the comment section in
the box to relay that information...or you may wish to use that space to
provide some clarification of your choices. "n.o.c." means not otherwise
classified. If this is a recordable case, you must provide corrective
actions to address and eliminate, if possible the direct cause of the
accident\... If the root cause is identified, the actions recommended
should reflect plans to minimize and omit it. If the risk is acceptable
otherwise, indicate "Not Applicable." When providing corrective actions,
you must indicate who will be responsible and when it will be completed.
If you need to investigate the incident further by talking with
witnesses, please fill in the information requested.

Section H: In the course of your investigation of any case involving
those items listed, the OMC has probably already referred the case, but
you should follow-up by contacting the Industrial Hygiene Group for
assistance and/or confirmation that a condition exists and get IH
recommendations to ameliorate the issues if possible.

Section I: [Completion of this section is required only if there is
restricted work and/or days are lost away from work.]{.underline} If
there is no associated lost time (Restricted Workdays or Days Away From
Work) beyond the initial date of injury/illness, do not fill in this
section.

Section J: This section is intended for those cases that need special
attention. Please answer accordingly and refer to those SBMS areas
indicated.

Section K: [Completion of this section is required for all Type C
Investigations.]{.underline}

Section L: This section is provided for the Line Organization's
Comments. Completion is not required for these investigations. It merely
provides space for comments and room for the Line to review the reports
for completion prior to sending same to Safety Engineering for input
into internal database (OSMIS) or submittal to CAIRS.

Section M: This section is reserved for Safety Engineering Use only.

Completed Investigations must be signed and forwarded to Safety
Engineering Group Leader, Bldg. 120 or sent electronically to
<ellerkamp@bnl.gov>.

Line Organization Accident/Incident Investigation Report

BROOKHAVEN NATIONAL LABORATORY

# Upton, New York 11973-5000

**[PART 1]{.underline}** Case Number (Optional): \_\_\_\_\_\_\_\_\_\_

## Who was involved in this accident/incident? (The first name should be the victim/injured/ill person):

+------------+--------+----------+------+---------+--------+--------+
| Name       | Occu   | H        | Life | Te      | Line   | Superv |
|            | pation | ospital, | #/ID | lephone | Organi | isor's |
|            |        | if       |      | \# at   | zation |        |
|            |        | tra      |      | wo      |        | Name   |
|            |        | nsported |      | rkplace |        |        |
+------------+--------+----------+------+---------+--------+--------+
|            |        |          |      |         |        |        |
+------------+--------+----------+------+---------+--------+--------+
|            |        |          |      |         |        |        |
+------------+--------+----------+------+---------+--------+--------+
|            |        |          |      |         |        |        |
+------------+--------+----------+------+---------+--------+--------+

B. **Job Classification**

\[ \] Bargaining Unit \[ \] Exempt \[ \] Non-Exempt \[ \]
Non-Employee/Contractor \[ \] Non-Employee/Other

\[ \] Full-Time \[ \] Part-time \[ \] Student \[ \] Other (Please
specify: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

C. When was the Occurrence (as reported by Employee/Non-Employee)?
\_\_\_/\_\_\_/\_\_\_\_ Time: \_\_\_\_\_\_AM/PM

When was the date of Notification to BNL Line Organization/OMC/Other
Employer? \_\_\_/\_\_\_/\_\_\_ How?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Where did this Event happen?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\[ \] On-site \[ \] Off-site

**Type of Accident/Incident:** \[ \] Injury/Illness \[ \] Property \[ \]
Vehicle \[ \] Radiological \[ \] Environmental \[ \] Near Miss

**BNL Investigation Type**: \[ \] Type C \[ \] First Aid \[ \] Near Miss
\[ \] MVA \[ \] Contamination \[ \] Fire \[ \] Other

D. If victim or injured/ill person is not a BNL employee, please
indicate identity of employer here. \[ \] Not Applicable
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

E. ***[OSHA Information (Injury/Illness):]{.underline}*** Death? \[ \]
Yes \[ \] No

\[ \] Injury Does this case involve Days Away from Work? \[ \] Yes \[ \]
No

\[ \] Skin Disease or Disorder Are there Multiple Victims? \[ \] Yes \[
\] No

\[ \] Respiratory Conditions Was the employee hospitalized overnight? \[
\] Yes \[ \] No

\[ \] Poisoning Was there an on-the-job transfer or restriction? \[ \]
Yes \[ \] No Has the employee returned to full duty? \[ \] Yes \[ \] No

\[ \] All Other Illnesses If applicable, has employee brought BTW slip
from OMC? \[ \] Yes \[ \] No

Experience on this task: \[ \] under 3 months \[ \] 3-12 months \[ \]
over 12 months

F. ***[For Property/Vehicle and/or Radiological or Environmental Losses
only (otherwise skip this section):]{.underline}*** \[ \] Not Applicable

**Property Loss Type:**

Fire/Smoke: \[ \] Building \[ \] Equipment \[ \] Brush \[ \] Vehicle \[
\] Other

Electrical: \[ \] Equipment Contact \[ \] Wiring \[ \] Overload \[ \]
Insulation \[ \] Polarity \[ \] Grounding \[ \] Other

Explosion: \[ \] Vapor \[ \] Chemical \[ \] Fluids \[ \] Dust

Mechanical: \[ \] Linear energy \[ \] Rotational energy \[ \] Pressure
\[ \] Falls \[ \] Mechanical breakdown \[ \] Overload

Acts of Nature: \[ \] Wind \[ \] Rain/Hail \[ \] Freezing rain \[ \]
Snow \[ \] Lightning \[ \] Earthquake \[ \] Other

Leaks, Spills,

Releases, or

Contamination: \[ \] Chemical \[ \] Biological \[ \]
Nuclear/Radiological \[ \] Environmental Impairment/Impact \[ \]
Poisoning \[ \] Other

Miscellaneous: \[ \] Thermal Damage \[ \] Corrosion \[ \] Water Damage
\[ \] Sabotage \[ \] Other

**Vehicle Loss Type: \[ \] Government-owned \[ \] Contractor-owned \[ \]
Personal/Privately-owned \[ \] Other**

Light Highway: \[ \] Automobile \[ \] Van \[ \] Cushman-type vehicle

\[ \] Pickup Truck \[ \] Motorcycle, moped \[ \] Highway vehicle. n.o.c

Heavy Highway: \[ \] Bus \[ \] Delivery Truck \[ \] Dump truck \[ \]
Semi \[ \] Crane \[ \] Truck, n.o.c.

Construction Vehicles:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Other Vehicles:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Was vehicle equipped with seat belts? \[ \] Yes \[ \] No

Did vehicle accident involve a recordable injury? \[ \] Yes \[ \] No

Did equipment design or defect contribute to accident cause or severity?
\[ \] Yes \[ \] No

Total Damage: \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (if known)

**[PART 1 (Continued):]{.underline}**

G. Line Management was notified by
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date/Time:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Manager notified:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Title:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#### *[REQUIRED INVESTIGATION INFORMATION (ALL CASES)]{.underline}*

H. What was the **[activity]{.underline}** in progress at the time of
the accident/incident and why was it being performed?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How often is this activity performed (generally)? \_\_\_\_\_\_\_\_\_\_\_
How often is this activity performed by this individual?
\_\_\_\_\_\_\_\_\_\_\_\_

I. Was a supervisor present at the scene at the time of the incident? \[
\] Yes \[ \] No

J. **[Describe the accident sequentially]{.underline}**, beginning with
initiating events. Tell what happened, how it happened and end with the
nature and extent of injury or damage.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

K. Describe the **nature and severity of the incident,** use preliminary
diagnosis of medical professional if known (e. g. right shoulder strain/
chemical spill/ radiological contamination/vehicle accident, etc.)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**L. Body Part (s) Injured:**

**\[ \] Abdomen \[ \] Eye \[ \] Head \[ \] Mouth \[ \] Shoulder**

**\[ \] Ankle \[ \] Face \[ \] Heart \[ \] Multiple Parts \[ \] Skull**

**\[ \] Arm \[ \] Finger \[ \] Hip \[ \] Musculo-skeletal System \[ \]
Testicle**

**\[ \] Back \[ \] Finger -- 1^st^ \[ \] Hips \[ \] N/A \[ \] Thigh**

**\[ \] Brain \[ \] Finger -- 2^nd^ \[ \] Jaw \[ \] Neck \[ \] Throat**

**\[ \] Buttock \[ \] Finger -- 3^rd^ \[ \] Kidney, Bladder, Intestine
\[ \] Nervous System \[ \] Thumb**

**\[ \] Cardiopulmonary \[ \] Finger -- 4^th^ \[ \] Knee \[ \] Nose \[
\] Toe**

**\[ \] Chest \[ \] Finger -- 5^th^ \[ \] Leg \[ \] Other \[ \] Tooth**

**\[ \] Digestive System \[ \] Foot \[ \] Lip \[ \] Pulmonary System \[
\] Torso**

**\[ \] Ear \[ \] Groin \[ \] Lung \[ \] Respiratory System \[ \]
Unknown**

**\[ \] Elbow \[ \] Hand \[ \] Lungs \[ \] Scalp \[ \] Wrist**

M. Name of outside (non-BNL) **medical provider**, if applicable \[ \]
Not Applicable
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Hospital**, only if admitted overnight (not ER)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**N. PLEASE NOTE: If this is a First Aid Case, complete the signature
block below. Part 2 is optional for first aid cases. If this is a
recordable case, skip this box and proceed to Part 2.** \[ \] Not
Applicable

[Investigated by:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[Employee Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[Bargaining Unit Rep (if applicable):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[Line Authority (Supervisor/Designee) Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[Line ESH Coordinator or other Designated Safety Person:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[]{.mark}

**[PART 2: (*THE FOLLOWING IS REQUIRED FOR ALL INVESTIGATIONS OF CASES
MEETING THE OSHA GENERAL RECORDKEEPING CRITERIA FOR RECORDABLE CASES.
*]{.underline}[Please complete ONLY those sections that apply]{.mark}.
This part is optional for First Aid Cases and Near Misses.)**

[]{.mark}

##### [Walking and Working Surfaces]{.underline}: \[ \] Not Applicable

##### \[ \] Dry \[ \] Wet \[ \] Slippery \[ \] Not Specified \[ \] Not Applicable 

\[ \] Grass/Soil \[ \] Tile, Concrete or Wood Floor \[ \] Stairs \[ \]
Ladder \[ \] Ramp \[ \] Pavement/Sidewalk \[ \] Parking Lot \[ \]
Platform \[ \]Other Elevated Surface \[ \] Confined Space \[ \]
Roadway/Street \[ \] Not Specified \[ \] Not Applicable \[ \]Other ,
Specify:\_\_\_\_\_\_\_\_\_\_\_\_\_

A.  **[Outdoor and Weather-related:]{.underline}** If this was **an
    outdoor activity, or if weather related** to the incident in any
    way, please complete the following by checking all that apply: \[ \]
    Not Applicable

\[ \] Snow/Sleet-related \[ \] Ice-related \[ \] Rain/Water-related \[
\] Wind-related/Hurricane-related \[ \] Extreme Hot/Cold-related \[ \]
Response-related \[ \] Athletic/Recreational

B.  **[Tool, Machine or Equipment-related]{.underline}**, please check
    those that apply, or Other: \[ \] Not Applicable

\[ \] Fixed Machinery, please identify:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Non-powered Hand Tool, please identify:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Portable Electric Tool, please identify:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Portable Compressed Air-driven Tool, please identify:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Laboratory Equipment, please identify:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Office Equipment, please identify:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Maintenance Equipment, please identify:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Other, please identify:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is this equipment on a **Preventive Maintenance Schedule**? \[ \] Yes \[
\] No If so, date of last PM was \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Was **Lockout/Tagout** applicable? \[ \] Yes \[ \] No Was employee
authorized for this procedure? \[ \] Yes \[ \] No

D. [Miscellaneous]{.underline}, please check those that apply: \[ \] Not
Applicable

Was a **Job Risk Assessment or Hazard Analysis** performed for this job?
\[ \] Yes \[ \] No

If no, is one scheduled? \[ \] Yes \[ \] No When?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Was this employee involved in the **work planning**? \[ \] Yes \[ \] No

Was this job considered **"skill of the craft"**? \[ \] Yes \[ \] No
Why? \_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What **feedback** has the employee given about this job?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What **[Personal Protective Equipment]{.underline}** was provided for
this job?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If Personal Protective Equipment was required for this job, was it worn?
\[ \] Yes \[ \] No

Was it worn properly? \[ \] Yes \[ \] No

Was a special **permit (hot work, confined space, radiological, etc.)**
required for this job? \[ \] Yes \[ \] No
Why?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is all of this person's **applicable training** current for this job? \[
\] Yes \[ \] No

E.  [If **Vehicle(s)**]{.underline} were involved, please complete the
    following by checking the applicable items: \[ \] Not Applicable

\[ \] Rented Vehicle, Type: \_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Personally-owned vehicle, Type: \_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Government-owned vehicle Type: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Construction Equipment Type:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Was vehicle equipped with a seat belt? \[ \] Yes \[ \] No

Was it used at the time of the incident? \[ \] Yes \[ \] No

**[PART 2 (Continued):]{.underline}**

F.  [Hazards Identified]{.underline} as part of this event: (Required
    for Type C Investigations.)

> \[ \] Not Applicable

\[ \] Integrated Safety Management Hazard Recognized
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Manual Material Handling, less than 20 lbs \[ \] Flying particles

\[ \] Manual Material Handling, more than 20 lbs \[ \] Point of
Operation

\[ \] Keyboarding, data entry or manipulation \[ \] In-going Nip Points

\[ \] Risk of Possible Biological exposure \[ \] Poor/Inadequate/No
Lighting

\[ \] Risk of Possible Chemical exposure \[ \] Possible Noise exposure

\[ \] Risk of Possible Radiological exposure \[ \] Rotating
Part(s)/Rotating Blade(s)

\[ \] Workstation Design/other Ergonomic issues \[ \] Traffic-Related
Problem

\[ \] Unacceptable Behavior \[ \] Sharp edges

\[ \] Unprotected low hanging surfaces \[ \] Other (Please Specify)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[]{.mark}

####### Accident Causes (REQUIRED) (Please indicate your choice of the Direct \[or immediate cause\] by placing a "D" in front of that item on the list. Do the same for Contributing ("C") and Root ("R") causes. Please remember that there may be more than one of each. If you do not know, or do not wish to go through this exercise, pass it up the Line. PLEASE NOTE: This section must be completed by the Line Organization and should be used to help determine corrective actions. The report will be reviewed by Safety Engineering and incomplete reports will be returned prior to submittal of CAIRS Reports to DOE. 

#######  

\_\_ Equipment/Material Problem, n.o.c. \_\_ Personal Error \_\_ Error
in Equipment or Material Selection

\_\_ Defective or Failed Part \_\_ Inadequate work environment \_\_
Drawing, spec or data errors

\_\_ Defective or Failed Material \_\_ Inattention to
detail/surroundings \_\_ Training issues, n.o.c.

\_\_ Defective Weld, brazed, or soldered joint \_\_ Other Human Factors
Error \_\_ Inadequate Supervisor or Admin. Control

\_\_ Error by Manufacturer, or in Shipping \_\_ Design Problem, n.o.c.
\_\_ Work Org. & Planning Deficiency

\_\_ Noise, electrical, instrument, machine \_\_ Verbal communication
Problem \_\_ Management Problem, n.o.c.

\_\_ Contamination \_\_ Violation of requirement/procedure \_\_
Inadequate Barriers

\_\_ Defective or Inadequate Procedure \_\_ Inadequate or defective
design \_\_ Fire/Explosion/Vandalism/Weather

\_\_ Lack of Procedure \_\_ Inadequate man/machine interface \_\_
Theft/Sabotage/Power Failure

\_\_ Procedure Problem, n.o.c. \_\_ Inadequate surface preparation \_\_
External Phenomena, n.o.c.

\_\_ Other (not otherwise classified \[n.o.c.\]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Comments on Causality (not required, but may be used for clarity):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Corrective Actions:]{.underline}** (Should address any causes identified
\[See above, Section G\] If a First Aid case and risk is acceptable,
corrective actions may not be necessary. If so, indicate "Not
Applicable". However, if this is a recordable case, corrective actions
are required.)

1\. **Immediate Actions to Mitigate Direct Cause of Accident/Incident:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. **Actions Recommended to mitigate Contributing and Root Causes:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. If a corrective action was required, who is responsible for its
completion?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### 

4\. When will it be completed?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### If Follow Up (is/was needed): Names of Witnesses/Others to be Interviewed \[ \] Not Applicable

H. [Cases Needing Referral to, or Follow up by, Industrial
Hygiene]{.underline}: (***Please Note: If there is a report that any of
those conditions asterisked (\*) below occur, you must contact the
Industrial Hygiene Group of the Safety & Health Services Division for
help in further evaluation and/or ameliorization of the problem. EACH of
these may be OSHA Recordable incidents and a more complete investigation
may be necessary.)***

**If this is an occupational illness or chronic condition**, **\*please
check those that apply.** \[ \] Not Applicable

\[ \] Allergic reaction to bites or stings

\[ \] Chemical Sensitization \*

\[ \] Contact Dermatitis or other skin disease or disorder

\[ \] Pleural Plaques, Asbestosis, Silicosis, breathing hazardous
biological agents, Beryllosis or other dust, gas, vapor, or fumes
resulting in toxic inhalation and other diseases of the lungs \*

\[ \] Tuberculosis infection (positive skin reaction or medical
professional's diagnosis following exposure) \*

\[ \] Poisoning evidenced by abnormal concentrations of toxic substances
in the blood (such as lead, cadmium, mercury, other metals, carbon
monoxide, benzene, insecticide sprays, formaldehyde \*

\[ \] Needle stick or injury from a sharp object that may be
contaminated with blood or other potentially infectious material \*

\[ \] Cancer, or other chronic irreversible disease \*

\[ \] Case requiring an employee to be removed from work under the
requirements of an OSHA health standard \*

\[ \] Effects of environmental heat (heat stress, sunstroke) \*

\[ \] Effects of exposures to low temperatures (frostbite) \*

\[ \] Effects of non-ionizing radiation (welding flash, lasers) \*

\[ \] Exposure to anthrax, bloodborne pathogens (AIDS, HIV, hepatitis B
or C, etc.) \*

\[ \] Muscular-skeletal Disorders (MSDs) resulting from cumulative
trauma (white finger syndrome, certain losses of function) or repetitive
motion (carpal tunnel syndrome) in conjunction with general recording
criteria. \*

\[ \] Standard Threshold Shift of \>25 decibels on the A scale in the
2000-4000 Hertz Range in either ear from established baseline \*

\[ \] Other (Please explain):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> **[I. Lost Workday Information]{.underline}**
>
> \[ \] Not Applicable
>
> \[ \] Information not yet available

**Days Away From Work:**

First Full Day Missed: (MM/DD/YY)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \[ \] Did not return to work on
the next day

\[ \] Returned to work, anticipate no further lost time

Return to Work Day: (MM/DD/YY)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \[ \] Sent Home Sick on day
of event

**Restricted Workdays:**

First Full Day Assigned: (MM/DD/YY) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Day returned to Full Duty: (MM/DD/YY) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[ \] Information does not apply

**Was a Return-to-Work Plan developed for this incident? \[ \] Yes \[ \]
No** \[ \] Information not yet available

Describe Restrictions:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[J. Is Special Attention Needed]{.underline}**? \[ \] Not Applicable

Is this an ORPS event? \[ \] Yes \[ \] No

HAVE YOU CONTACTED THE ORPS CATEGORIZER (631-433-0443)? \[ \] Yes \[ \]
No

Has a separate BNL or DOE **investigation Board or committee** been
assigned/charged? \[ \] Yes \[ \] No

Has this report been forwarded to the organization's **Lessons Learned
Coordinator**? \[ \] Yes \[ \] No If yes, when? \_\_\_\_\_

Has the organization's **ESH Coordinator** been notified? \[ \] Yes \[
\] No

If this involves another organization, has a copy been provided to that
organization? \[ \] Yes \[ \] No

Please note other organization and the date they were notified:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

###### [K. TYPE C INVESTIGATION SIGNATURE BLOCK]{.mark}

[]{.mark}

[Report Prepared by:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[]{.mark}

[Employee Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[]{.mark}

[Bargaining Unit Rep (if applicable):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[]{.mark}

[Line Authority (Supervisor/Designee) Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[]{.mark}

[Line ESH Coordinator or other Designated Safety Person:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[]{.mark}

[Manager Approval:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.mark}

[]{.mark}

L**[. Reviewer's/Manager's Notes:]{.underline}**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[M. Comments by Safety Engineering:]{.underline}**

**[Forward for CAIRS Report\_\_ \_\_\_\_\_\_\_\_\_\_ \[ \] Yes \[ \]
No]{.underline}**

**[Reject and return to Line Manager\_\_\_\_\_\_]{.underline}**
**Workers' Compensation Claim filed**? **\[ \] Yes \[ \] No**

**[Reasons for
Rejection\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}**

Rev F (02/10/07)