CONTRACTORS PERSONAL INJURY REPORT

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					                                     CONTRACTORS PERSONAL INJURY REPORT

Company _______________________                               Dept _____________                Location_________________

 INJURY REPORT                     NEAR MISS

THIS FORM IS TO BE COMPLETED BY CONTRACTOR FOR ALL INJURIES REQUIRING PROFESSIONAL MEDICAL TREATMENT
AND SEND COPIES TO SAFETY SUPERVISOR, PLANT ENGINEER, MANAGER OF MAINTENANCE, PURCHASING, OWNER’S
REPRESENTATIVE

CONTRACTOR
CONTRACTOR:____________________________________ EMPLOYEE:___________________________________________________
PROJECT DESCRIPTION:____________________________ SSN:___________________________________________________________
____________________________________________________ OCCUPATION WHEN INJURED:_________________________________
LOCATION (Be Specific)______________________________ ADDRESS:_____________________________________________________
____________________________________________________ PHONE # ___________________ CITY/STATE:_____________________



ACCIDENT INFORMATION
DATE OF ACCIDENT/INJURY:____________________________HOUR OCCURRED: AM__________ PM _______________
DESCRIPTION OF ACCIDENT/NEAR MISS:___________________________________________________________________________

_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

ACTION TAKEN TO PREVENT A RECURRENCE OF ACCIDENT:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

NAMES & ADDRESS OF WITNESS:
_________________________________________________________________________________________________________



INJURY
INJURY BODY PART:                ________________________________________________________________________________

DOCTORS DIAGNOSIS & TREATMENT (Be specific i.e. Laceration of hand – Sutures & Prescription Medicine)
________________________________________________________________________________________________________
________________________________________________________________________________________________________

RESTRICTIONS (Be specific – i.e. lifting of weights over 30 lbs. No climbing, etc.)
________________________________________________________________________________________________________
________________________________________________________________________________________________________

EXAMINED BY:_____________________________________________ DATE OF EXAMINATION:_______________________________


CONTRACTOR FOREMEN:______________________________________                      CONTRACTOR SUPT:_______________________________
OWNER’S REPRESENTATIVE:__________________________________

   O
OWNER’S SAFETY SUPERVISOR
   DOCTOR/FIRST AID                                                     LOST TIME ACCIDENT

     DOCTOR/RECORDABLE                                                  FATALITY

     RESTRICTED WORKDAY \
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OWNER’S SAFETY SUPERVISOR:______________________________________________ DATE:_______________________________




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