Law Department notice on WTC document preservation, Oct 2001

NYC 9/11 Public Portal Document

WRS INFRASTRUCTURE & ENVIRONMENT, INC. INJURY/ILLNESS/INCIDENT INVESTIGATION AND REPORT (OSHA 301 Form Equivalent) Supervisor Complete Both Pages/Forward to Branch and WRS H&S Manager within 48 hrs./Supervisor's Manager Review for Completeness 1. What Occurred Describe in sequence (1) relevant background information if any, (2) employee's location and position relative to immediate surroundings, (3) how employee was doing job, (4) what occurred that precipitated the accMent, (5) the type of accident and contact agent

2. Contributing "Unsafe" Action What did the injured (or other 3. Contributing "Unsafe" Condition What defective or otherwise person) do or fail to do that contributed directly to accident? Be unsafe conditions of tools, equipment, machines, structures or work specific. equipment contributed directly to accident? Failed to use protective equipment. Failed to lock out machine) (Ex., oil on floor. Broken or missing machine guard, Poor housekeeping) Don't report “Carelessness.*

Part 2. Corrective Action Must Be Taken 4. Required Corrections What corrective actions will be taken to prevent recurrence of accident? See Reverse Side, Item 35, for basic correction ideas. (Fx., Job Safety Analysis (JSA), Training, Emptoyee counseling, Machine Guarding)

----- Parts. Witnesses: . ,'*1! 77 Part 4. Accident Location Sketch N

parts. Extent and Outcome Of Injury/lllness Lost Time Case Restricted Duty Case Restrictions: - Date Lost Time Began: / / Date Restriction Began; /__ / - Date Lost Time Ended: 7 i Date Restriction Ended: / / Medical Treatment - Name of Hospital or Clinic:

- Name of Physician:

Describe Treatment:

Was employee treated in an Emergency Room? Yes □ No □ Was employee hospitalized overnight as an in-patient? Yes □ No u

-001 WRS Infrastructure and Environment, Inc. 28

NYC-WTC_000145105