--------------------------------- -------------------------------------
  SF SF 2050-P (3-2006) Supersedes  
  (12-00) issue                     

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**UCI**

> Sandia National Laboratories

**REPORT OF OCCUPATIONAL INJURY/ILLNESS**

(Based on the OSHA definitions and requirements which may or may not be
consistent with various state compensation laws)

*NOTICE OF INCIDENT*

(Pursuant to Chapter 52, NMSA 1978 section 52-1-29)

**Instructions:** All personnel are required to complete page 1 of this
form (e.g., employees at remote sites, contractors). Page 2 pertains
only to contracting personnel.

<table>
<colgroup>
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<col style="width: 4%" />
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<col style="width: 3%" />
<col style="width: 4%" />
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<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="4">Date received in Medical</td>
<td colspan="7"><strong>     </strong></td>
<td></td>
<td colspan="8">Case No.</td>
<td colspan="10"><strong>     </strong></td>
<td></td>
<td colspan="20">Date received in Injury/Illness Reporting</td>
<td colspan="4"><strong>     </strong></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5"><p>Name(Last, First, MI)</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>Org.</p>
<p><strong>     </strong></p></td>
<td colspan="8"><p>Mail Stop</p>
<p><strong>     </strong></p></td>
<td colspan="6"><p>Sex</p>
<p><strong>     </strong></p></td>
<td colspan="10"><p>Date of Birth</p>
<p><strong>     </strong></p></td>
<td colspan="11"><p>Age</p>
<p><strong>     </strong></p></td>
<td colspan="12"><p>Social Security Number</p>
<p><strong>     </strong></p></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"><p>Date of Incident</p>
<p><strong>     </strong></p></td>
<td colspan="5"><p>Incident Day of Week</p>
<p><strong>     </strong></p></td>
<td colspan="11"><p>Time of Day</p>
<p><strong>     </strong></p></td>
<td colspan="19"><p>Location of Incident (Bldg/Room)</p>
<p><strong>     </strong></p></td>
<td colspan="15"><p>Incident was:</p>
<p><strong>     </strong> Inside/Outside</p></td>
<td colspan="3"><p>Hire Date</p>
<p><strong>     </strong></p></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="26"><p>Job Category (Secretary, electrician, painter,
scientist, mechanical tech, etc)</p>
<p><strong>     </strong></p></td>
<td colspan="18"><p>Job experience [(yr(s)mo(s)]</p>
<p><strong>     </strong></p></td>
<td colspan="11"><p>Witness(es)</p>
<p><strong>     </strong></p></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="55"><p>Type of Injury/Body Part</p>
<p><strong>     </strong></p></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="55">Briefly describe the activity you were performing and
how the incident occurred <strong><u>     </u></strong></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="13"></td>
<td colspan="2"></td>
<td colspan="22"><strong>     </strong></td>
<td colspan="3"></td>
<td colspan="15"><strong>     </strong></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="13">Employee Signature</td>
<td colspan="2"></td>
<td colspan="22">Work Phone</td>
<td colspan="3"></td>
<td colspan="15">Date</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="55">INVESTIGATION - MANAGER (Foreman, Inspector, etc.)</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="27">A. Was place of Incident or exposure on Sandia’s
premises</td>
<td colspan="29">Yes No </td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="27">B. Was employee sent home due to incident?</td>
<td colspan="29">Yes No </td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="27">C. What was the employee doing when incident occurred?
Be Specific</td>
<td colspan="29"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="48">Describe the tasks the individual was doing when the
injury occurred. Describe the environment including controls where the
injury or illness occurred (e.g., employee walking on rocky path,
employee spends 6 to 8 hours working on the computer.)</td>
<td colspan="7"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="56"><strong><u>     </u></strong></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="56"><p>D. Describe what happened. Construct the sequence of
events that led up to the incident. Describe the incident. Was the work
adequately planned? Was the work adequately supervised? Were hazards
identified? Were controls specified and were they used? What PPE was
being used?</p>
<p><strong><u>     </u></strong></p></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="56"><p>E. What has been done to correct conditions causing
the incident? List any corrective actions taken.</p>
<p><strong><u>     </u></strong></p></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="56"><p>F. How can this incident or injury be mitigated in
the future. List any corrective actions that are recommended. By what
date?</p>
<p><strong>     </strong></p></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="6">Manager’s Name (print or type)</td>
<td colspan="35"><strong>     </strong></td>
<td colspan="15"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">Manager’s Signature</td>
<td colspan="20"></td>
<td colspan="5">Org</td>
<td colspan="7"><strong>     </strong></td>
<td colspan="7">M.S.</td>
<td colspan="6"><strong>     </strong></td>
<td colspan="8"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="25"></td>
<td colspan="4">Date</td>
<td colspan="9"><strong>     </strong></td>
<td colspan="7">Phone</td>
<td colspan="9"><strong>     </strong></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="56"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="58"><p><em><strong>UCI</strong></em></p>
<p><strong>(Page 2 - Pertains to Contracting Personnel
Only)</strong></p></td>
</tr>
<tr class="odd">
<td colspan="58"><strong>CONTRACTOR INFORMATION</strong> - PLEASE
COMPLETE THE FOLLOWING INFORMATION</td>
</tr>
<tr class="even">
<td colspan="11"><p>Contractor Company Name</p>
<p><strong>     </strong></p></td>
<td colspan="9"><p>Phone</p>
<p><strong>     </strong></p></td>
<td colspan="20"><p>Name of SNL Supervisor /Inspector</p>
<p><strong>     </strong></p></td>
<td colspan="7"><p>Org.</p>
<p><strong>     </strong></p></td>
<td colspan="7"><p>M.S.</p>
<p><strong>     </strong></p></td>
<td colspan="4"><p>Phone</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="20"><p>Workdays Lost</p>
<p><strong>     </strong></p></td>
<td colspan="38"><p>Workdays Restricted</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="58"><strong>OSHA RECORDABILITY DETERMINATION</strong> (To
Be filled out by Contracting Company)</td>
</tr>
<tr class="odd">
<td colspan="10"><p><strong>Diagnosis</strong></p>
<p>     </p>
<p> Contusion</p>
<p> Fracture</p>
<p> Laceration</p>
<p> Loss of Consciousness</p>
<p> Strain/Sprain</p></td>
<td colspan="25"><p><strong>Treatment</strong></p>
<p> First Aid Only</p>
<p> Sutures</p>
<p> Prescription Medication</p>
<p> OTC Medication</p>
<p> Steri-strip/Butterfly</p>
<p> Splint (Support)</p>
<p> Splint (Immobilize)</p>
<p> Other: ______________________</p>
<p>(please explain)</p></td>
<td colspan="23"><p><strong>Disposition</strong></p>
<p> Outside Referral</p>
<p> Physical Therapy</p>
<p> Sent Home</p>
<p> Accommodations</p>
<p> None of the Above</p></td>
</tr>
<tr class="even">
<td colspan="58"><p>Examined by physician/NP/PA? Yes No Attending
medical professional name:</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="22"></td>
<td colspan="36"></td>
</tr>
<tr class="even">
<td colspan="58"><strong>INJURY AND ILLNESS REPORTING USE
ONLY</strong></td>
</tr>
<tr class="odd">
<td colspan="58">DOE Case Recordable Yes No </td>
</tr>
<tr class="even">
<td colspan="58"><p>Investigative Comments See Attachment Not Work
Related </p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="15">     </td>
<td colspan="3"></td>
<td colspan="7">     </td>
<td colspan="2"></td>
<td colspan="7">     </td>
<td colspan="3"></td>
<td colspan="11">     </td>
<td colspan="3"></td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="15">Safety Reporting Administrator</td>
<td colspan="3"></td>
<td colspan="7">Org</td>
<td colspan="2"></td>
<td colspan="7">M.S.</td>
<td colspan="3"></td>
<td colspan="11">Phone</td>
<td colspan="3"></td>
<td colspan="7">Date</td>
</tr>
<tr class="odd">
<td colspan="58"></td>
</tr>
</tbody>
</table>