HomeMy WebLinkAboutDocumentation_Safety_Tab 4A_10/9/1998 WATER DEPARTMENT
SUPERVISOR'S ACCIDENT INVESTIGATION REPORT
Employee Name 1-Ffi�/11 rim ' Date of Accident ) _ 7 - 99
Location of Accident I,l9ft7 L PLA')Or' Time.of Accident f€. 3o Poi
Occupation of Employee_PL. t),- C '�a Injury Cctr- 04)
Witness Reviewed by Management
Employee's description of accident.
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What acts, failures to act and/or conditions contributed most directly to this accident?
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What are the reasons for the existence of these acts and/or conditions?
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What is the plan of action to prevent recurrence?
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Supervisor's Comments: rS cL _ c A-0 d W i ILL
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Investigated by: 1-0(A ( F/ l�li Reviewed by:
Date: 1 SO ^ 7 Date: 2, to -?7