Attachment 5 - Contractor Employee Injury Report.pdf

Injured/Ill Employee Information

Last Name: First Name:

Gender: Company Name:

Shop (Pay Shop):

Date/Time of Incident

Date incident occurred:

Time incident occurred:

Which shift was the employee working when the incident occurred:

Time that employee began work on the day of the incident (e.g. 0630):

Was the employee working Overtime at the time that the incident occurred:

Location Where the Incident Occurred

Facility/location where the incident occurred:

If it occurred in/on a submarine, or in/beside a dry dock as a direct result of work supporting the repair/overhaul of a submarine, select which one: Submarine SSN #:

If it occurred in a building or other named structure, select which one: Building or Other Structure:

If it did not occur in/on a submarine, building, or structure, describe the location in which it occurred (e.g., Isaac Hull Street, Jamaica Island Parking Lot, etc.):

Describe the specific area in which the incident occurred (e.g., New Hampshire Conference Room, Forward Compartment AMR, Ballast Tank 5A, Welding School, Plastisol Dipping Area, Port Side SHT Enclosure 3rd Level Aft, etc.):

This information is subject to the Privacy Act of 1974

(FOUO When Filled In)

Description of Incident

Specific tool, equipment, object, or substance that caused the injury or illness (e.g., vertical turret lathe, Lincoln MIG welder, needle gun, space heater, concrete floor, epoxy paint, Armaflex 520 Adhesive etc.):

Work being performed at the time (e.g., welding of stainless steel battery cabinet shims, abrasive blasting using steel shot, walking from parking lot to office at the beginning of the shift, etc.):

Description of the incident - WHAT happened? HOW did it happen? WHY did it happen?

PPE worn at the time of the incident:

None Faceshield

Hard Hat Fall Protection Harness

Safety Glasses Life Jacket

Safety Shoes Air Purifying Respirator

Hearing Protection Air Supplied Respirator

Goggles Dust Mask

Cotton Gloves Leather Gloves

Cut Resistant Gloves Chemical Resistant Gloves

Cotton Coveralls Disposable Coveralls (e.g. Tyvek)

If contract employee was transported off-site, how was he/she transported:

To which medical facility was the contract employee transported:

Contract Employee's Current Work Status

Select all choices that are appropriate or provide additional information:

Contract employee resumed normal duties that shift or the following shift.

Contract employee did not return to work for the following shift.

Contract employee is currently out of work

Employee's Supervisor at the Time of the Incident

Last Name: First Name:

Company Name:

Submittal Information

Date Submitted: Time Submitted:

Submitted By:

Signature of Submitted By