Appointment of Site Manager letter COMPANY NAME & LOGO/LETTERHEAD OCCUPATIONAL OCCUPATIONAL HEALTH AND SAFETY ACT, 8 of !""# SECTION !$%&' ( ASSISTANT TO THE CHIEF E)ECUTI*E OFFICE+ APPOINTMENT (Appointee’s Name) I, (Appointe’s !"## Name) t$e (Le%is#atie e'eene o' Appointment) appointee o' (Appointe’s Aea) $ee* appoint *o" (Appointee’s !"## Name) as t$e +etion -(.) (Assistant to t$e CEO) appointee esponsi#e 'o t$e aea no0n as (Appointee’s Aea)1 Aea)1 In tems o' t$is Appointment, *o" ae esponsi#e 'o O"pationa# Hea#t$ an2 +a'et* mattes at t$e a'oementione2 aea1 In o2e to ens"e t$at *o" meet t$is esponsii#it* *o" m"st 'ami#iaise *o"se#' 0it$ t$e O"pationa# Hea#t$ an2 +a'et* At an2 its Re%"#ations1 Yo" ae a#so e3"ie2 to ens"e t$at a## stat"to* e3"iements ae met at a## times1 Yo ma- not frt.er a//ign t.i/ 0t-1 Yo" Appointment Appointment is a#i2 'om (+tat Date) to (En2 Date)1 Yo" s$a## epot (Time Peio2) 2iet#* to m*se#' on a## o"pationa# $ea#t$ an2 sa'et* mattes aisin% o"t o' (Appointee’s Aea)1 444444444444 (Appointe’s !"## Name)
44444444444444 Date
5in2#* on'im *o" aeptane o' t$is Appointment * omp#etin% t$e 'o##o0in%6 ACCEPTANC ACCEPTANCE E I, (Appointee’s !"## Name) "n2estan2 t$e imp#iations o' t$e Appointment as 2etai#e2 aoe an2 on'im m* aeptane1 4444444444441 (Appointee’s !"## Name)
444444444444411 Date
Site Con/tr2tion Sper3i/or form OCCUPATIONAL OCCUPATIONAL HEALTH 4 SAFETY ACT, 8 OF !""# !"" # Const"tion Re%"#ation - SUPE+*ISION OF 5UILDIN67CONST+UCTION O+9 I, 4444444444444444444, 2esi%nate2 as t$e 44444444444444444444 'o 444444444444444444 2o $ee* appoint *o" in tems o' +etion - o' t$e Const"tion Re%"#ations as SUPE+*ISO+ OF 5UILDIN6 O+9 Yo" aea o' esponsii#it* 0i## e 4444444444444444444444444444111 Yo" 2"ties 0i## in#"2e6 1 .1 71 91 ;1 -1 >1
?1
!ami !ami#i #ia ais ise e *o" *o"s se# e#'' 0it 0it$ $ t$e t$e e#e e#ea ant nt #e%i #e%is# s#at atio ion1 n1 +"pe +"pe is ise e t$e t$e sa'e sa'e pe pe'o 'om man ane e o' o' "i# "i#2i 2in% n% 0o 0o an2 an2 a#so a#so in e% e%a a2 2 to $ea# $ea#t$ t$11 Ca"s Ca"se e ee ee* * e8a e8aa ati tion on to to e ins inspe pete te2 2 * a om ompe pete tent nt pe peso son n one one e'o e'oe e ea$ ea$ s$i s$i't 't o o a'te an* ain, an2 ens"e t$at t$ese inspetions ae eo2e2 in a e%iste1 Ens" Ens"e e t$a t$att a## a## 0o 0oe es s "n2e "n2es sta tan2 n2 t$e t$e $a: $a:a a2s 2s att atta a$e $e2 2 to 0o 0o pe' pe'o ome me2 2 * t$em t$em11 / ?/@>/@7 @7 an2 t$e e#eant setions o' t$e OH+A1
4444444444444444141 +i%nat"e o' CEO/Emp#o*e
114444444 Date
ACCEPTANCE ACCEPTANCE I, 4444444444444444444444 $ee* aept t$is 2esi%nation an2 "n2estan2 an2 a%ee to omp#* 0it$ t$e e3"iements1 444444444444444 +i%nat"e
11444444444444 Date
A//i/tant Site Con/tr2tion Sper3i/or form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation - APPOINTMENT OF ASSISTANT CONST+UCTION O+9 SUPE+*ISO+ I, (Emp#o*e), 'o (Compan*) 2o $ee* appoint (Emp#o*ee) as t$e A//i/tant Sper3i/or of Con/tr2tion or: at (+ite/a22ess)1 Spe2ial In/tr2tion/7Information; 1 Assist t$e emp#o*e to omp#* 0it$ t$e O"pationa# Hea#t$ an2 +a'et* At, an2 espeia##* t$e Const"tion Re%"#ations1 .1 En2ose +a'et* Repesentaties’ epots/Min"tes o' t$e Hea#t$ an2 +a'et* meetin%1 71 Repot an2 inesti%ate an* ini2ent/ai2ent/in="*1 91 Ens"e t$e tems o' t$e BA%eement 0it$ Man2ato* as pe +etion 7>()(.) o' t$e At ae omp#ie2 0it$1 ;1 Ens"e is assessments ae on2"te2 0it$in *o" aea o' esponsii#it* an2 ae e%"#a#* "p2ate21 -1 Assist in ompi#in% Met$o2 +tatements an2 t$e 2ee#opment o' +a'e o Poe2"es1
+i%nat"e6 ('o Emp#o*e) Date6 Desi%nation6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is 2esi%nation1 +i%nat"e6 Date6 Desi%nation6
Healt. an0 Safet- Offi2er Appointment form OCCUPATIONAL HEALTH 4 SAFETY ACT, 8 OF !""# Const"tion Re%"#ation - HEALTH AND SAFETY OFFICE+ I, (Emp#o*e), 'o (Compan*) 2o $ee* appoint6 as t$e Hea#t$ an2 +a'et* O''ie 'o (site/a22ess)1 Dtie/; 1 Assist in ompi#in% t$e +HE P#an1 .1 Assist 0it$ is i2enti'iation, ea#"ation an2 2ee#opment o' sa'e 0o poe2"es1 71 Con2"t o $ae on2"te2 a is an2 $a:a2 ana#*sis an2 tae t$e neessa* oetie ation1 91 Ens"e a## ai2ents ae pope#* eo2e2, epote2 an2 inesti%ate21 ;1 Ens"e Hea#t$ an2 +a'et* Repesentaties ae appointe21 -1 Ens"e +a'et* Meetin%s ae $e#2 e%"#a#* an2 t$e es"#ts eo2e21 >1 Ens"e Hea#t$ an2 +a'et* Repesentaties on2"t mont$#* inspetions an2 s"mit t$e e3"ie2 epots1 ?1 Ens"e Contatos omp#* 0it$ t$e Hea#t$ an2 +a'et* +pei'iations1 1 Assist 0it$ esta#is$ment o' t$e !a## Potetion P#an1 @1 $ee it is not possi#e to emoe an* emainin% $a:a2/s *o" ae to in'om emp#o*ees t$eeo' an2 0$at pea"tiona* ation is to e taen1 1 Ens"e appopiate estoation o' aeas a''ete2 * onst"tion1 .1 Detai# miti%atin% meas"es e3"ie2 to e taen, an2 t$e poe2"es 'o t$ei imp#ementation to t$e Po=et Mana%e1 71 Esta#is$ t$e epotin% s*stem to e "n2etaen 2"in% onst"tion an2 ens"e e''etie epotin% to mana%ement on t$e 2eiations i2enti'ie2 an2 e3"ie2 ation to e taen1 91 Ens"e EMP omp#iane1 ;1 Ens"e mont$#* +a'et*, Hea#t$ an2 Enionmenta# epots ae s"mitte2 to t$e Po=et Mana%e1 -1 Ca* o"t too#o8 ta#s1 >1 Ens"e tainin% nee2s ae i2enti'ie2 an2 imp#emente21 ?1 Assist 0it$ In2"tion tainin%1 +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6
Date6
Desi%nation6
Appointment of Fall Prote2tion Planner form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 of !""# Const"tion Re%"#ation ? APPOINTMENT OF FALL P+OTECTION PLANNE+ I, (Emp#o*e), 'o (Compan*) 2o $ee* appoint 6 (Emp#o*ee) as t$e !a## Potetion P#anne 'o6 at (+ite/A22ess)1 Dtie/; 1 Ens"e omp#iane 0it$ Const"tion Re%"#ation ?1 .1 Compi#e a !a## Potetion P#an 'o t$e po=et1 71 Imp#ement t$e !a## Potetion P#an an2 amen2 0$ee e3"ie21 91 Tae steps to ens"e a## emp#o*ees a2$ee to t$e p#an1 ;1 Ens"e is assessments ae on2"te2 pio to ommenin% 0o in e#eate2 positions1 -1 Ens"e pesons e3"ie2 to 0o in e#eate2 positions ae p$*sia##* an2 ps*$o#o%ia##* 'it1 >1 Ens"e a## emp#o*ees e3"ie2 to 0o in e#eate2 positions ae taine21 ?1 Ens"e a## 'a## aest e3"ipment is inspete2 an2 maintaine21 1 Ens"e t$e onst"tion s"peiso is iss"e2 t$e #atest esion o' t$e !a## Potetion P#an1 @1 Ens"e a## $e#ists ae ept "p to 2ate, 0it$ opies in t$e Hea#t$ an2 +a'et* !i#e1 1 Ens"e oo' 0o is in#"2e2 in t$e p#annin%1 +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6 Desi%nation6
Appointment of E<2a3ation Sper3i/or form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 of !""# Const"tion Re%"#ation E)CA*ATION INSPECTO+7SUPE+*ISO+ I, (Emp#o*e), 'o (Compan*), 2o $ee* appoint (Emp#o*ee) as E<2a3ation In/pe2tor7Sper3i/or at (+ite/a22ess) *o" 0i## e e3"ie2 to ens"e t$at a## t$e poisions o' Const"tion Re%"#ation ae omp#ie2 0it$ an2 a## neessa* eo2s, e%istes an2 $e#ists ae ept "p to 2ate an2 in#"2e2 in t$e Hea#t$ an2 +a'et* !i#e1 +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6 Desi%nation6
Appointment of Demolition Sper3i/or form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation . APPOINTMENT OF DEMOLITION SUPE+*ISO+ I,(Emp#o*e), 'o (Compan*) $ee* appoint (Emp#o*ee) as t$e Demo#ition +"peiso at (+ite/a22ess)1 +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6 Desi%nation6 Appointment of S2affol0 Ere2tor form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation 9 APPOINTMENT OF SCAFFOLD E+ECTO+ I, (Emp#o*e), 'o (Compan*) $ee* appoint (Emp#o*ee) as t$e S2affol0 Ere2tor at (+ite/a22ess)1 Spe2ial In/tr2tion/7Information; +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is Appointment1
+i%nat"e6 Date6 Desi%nation6
Appointment of S2affol0 Team Lea0er form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation 9 APPOINTMENT OF SCAFFOLD TEAM LEADE+ I, (Emp#o*e), 'o (Compan*) $ee* appoint (Emp#o*ee) as t$e S2affol0 Team Lea0er at (+ite/a22ess)1 In/tr2tion/7Information; +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6 Desi%nation6
Appointment of S2affol0 In/pe2tor form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation 9 APPOINTMENT OF SCAFFOLD INSPECTO+ I, (Emp#o*e), 'o (Compan*) $ee* appoint (Emp#o*ee) as t$e S2affol0 In/pe2tor at (+ite/a22ess)1 +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6 Desi%nation6 Appointment of S2affol0 Sper3i/or form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation 9 APPOINTMENT OF SCAFFOLD SUPE+*ISO+ I, (Emp#o*e), 'o (Compan*) $ee* appoint (Emp#o*ee) as t$e S2affol0 Sper3i/or at (+ite/a22ess)1 +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6
Desi%nation6
Appointment of Material Hoi/t In/pe2tor form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation > APPOINTMENT OF MATE+IAL HOIST INSPECTO+ I,(Emp#o*e), 'o (Compan*) $ee* appoint (Emp#o*ee) as t$e Material Hoi/t In/pe2tor 'o (+ite/a22ess) Dtie/; Inspet Mateia# Hoist 2ai#* an2 ens"e omp#iane 0it$ Re%"#ations1 +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6 Desi%nation6
Appointment of 5at2. Plant In/pe2tor form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation ? +EF 5PL ! APPOINTMENT OF 5ATCH PLANT INSPECTO+ I, (Emp#o*e), 'o (Compan*) $ee* appoint (Emp#o*ee) as 5at2. Plant In/pe2tor 'o (+ite/a22ess)1 +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6 Desi%nation6
Appointment of 5at2. Plant Operator form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation ? APPOINTMENT OF 5ATCH PLANT OPE+ATO+ I, (Emp#o*e), 'o (Compan*) $ee* appoint (Emp#o*ee) as 5at2. Plant Operator 'o (+ite/a22ess)1 +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6 Desi%nation6
Appointment of To=er Crane Operator form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation .@ APPOINTMENT OF TOE+ C+ANE OPE+ATO+ I, (Emp#o*e), 'o (Compan*) $ee* a"t$oise (Emp#o*ee) to opeate as t$e To=er Crane Operator at (+ite/a22ess)1 +i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6 Desi%nation6
Appointment of Con/tr2tion *e.i2le an0 Mo>ile Plant In/pe2tor form OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# Const"tion Re%"#ation . APPOINTMENT OF CONST+UCTION *EHICLE 4 MO5ILE PLANT INSPECTO+ I, (Emp#o*e), 'o (Compan*) $ee* appoint (Emp#o*ee) as t$e Con/tr2tion *e.i2le 4 Mo>ile Plant In/pe2tor at (+ite/a22ess)1 Dtie/; 1 .1 71 91
Ens"e omp#iane 0it$ Const"tion Re%"#ation .1 Ens"e a## onst"tion e$i#es an2 moi#e p#ant ae inspete2 2ai#* pio to "se1 Ens"e onst"tion e$i#es an2 moi#e p#ant 0$i$ ae 'o"n2 to e "nsa'e ae 0it$2a0n 'om "se "nti# t$e e3"ie2 epais ae e''ete21 Ens"e eo2 is ept o' a## inspetions an2 t$e e%iste is ma2e aai#a#e as e3"ie21
+i%nat"e6 ('o Emp#o*e) Desi%nation6 Date6 ACCEPTANCE OF APPOINTMENT I, $ee* aept an2 "n2estan2 t$is Appointment1 +i%nat"e6 Date6 Desi%nation6
Appointment letter for Sta2:ing an0 Storage Sper3i/or OCCUPATIONAL HEALTH 4 SAFETY ACT, 8 OF !""# Genea# +a'et* Re%"#ations +etion ? STAC9IN6 AND STO+A6E SUPE+*ISO+ I, (Emp#o*e), 'o (Compan*) 2o $ee* appoint (Emp#o*ee) as t$e Sta2:ing an0 Storage Sper3i/or 'o (+ite/a22ess)1 Yo" 2"t* 0i## e to ens"e t$at a## stain%/stoa%e is aie2 o"t in ao2ane 0it$ Re%"#ation ? o' t$e Genea# +a'et* Re%"#ations ma2e "n2e t$e O"pationa# Hea#t$ an2 +a'et* At ?;/7 an2 an* ot$e #e%a# e3"iement o e8emptions 0$i$ ma* app#*1 +i%nat"e6 ('o Emp#o*e) Date6 ???????????????????????????????????????? Desi%nation6 ACCEPTANCE I, $ee* aept an2 "n2estan2 t$e e3"iements o' t$is 2esi%nation1 +i%nat"e6 Date6 Desi%nation6
Appointment letter a/ Fire Pre3ention an0 Prote2tion Control per/on FI+E P+E*ENTION AND CONT+OL %INCLUDIN6 E@UIPMENT SUITA5ILITY, MAINTENANCE 4 USA6E'1 <an$/site44444444444444Date 4444444444444 Dea 4444444444444444444 APPOINTMENT AS FI+E P+E*ENTION AND P+OTECTION OFFICE+ I $ee*, appoint *o" as t$e !IRE PREFENTION AND PROTECTION O!!ICER 'o 44444441 44444 (#oation) 'o t$e peio2 o' 4444444 mont$s 'om t$e 2ate o' t$is #ette1 Yo" 2"ties 0i## e to oo2inate an2 onto# t$e !ie Potetion an2 Peention Po%amme1 T$is 0i## in#"2e6 • • • •
•
•
To se#et !ie !i%$tin% Teams ('o t$e Da* s$i't an2 t$e Ni%$t s$i't)1 To a* o"t/o%anise 'ie e8tin%"is$in% tainin% as a%ee21 To $ae e%"#a MONTHLY !ie Di## Paties1 To ens"e t$at oet !ie !i%$tin% E3"ipment is aai#a#e an2 t$at it is in seiea#e on2ition at a## times1 To $ae an o%anise2 EFACATION ROTINE PROGRAMME an2 to $ae sta'' taine2 ao2in% to t$e po%amme1 To epot to 4444444444444444 on an* !ie Riss on t$e pemises1
Yo" 2"ties as t$e !ie Peention an2 Potetion O''ie 0i## 'om pat o' *o" n oma# 2"ties an2 e pe'ome2 2"in% 0oin% $o"s1 Emp#o*e 444444444444444114 Date 4444444444444
I, 44444411444444, $ee* aept t$is Appointment an2 ano0#e2%e t$at I "n2estan2 t$e nat"e o' m* 2"ties e#atin% t$eeto1 +i%ne2 4444444444444441 Date 4444444444444
per/onal prote2ti3e 2lot.ing a2:no=le0gement form ISSUE OF PE+SONAL P+OTECTI*E E@UIPMENT
N AME 6 44444444444444444441144441 C OMPANY N O6 4444444441444441 I, 444444444444444444 $ee* aept esponsii#it* 'o t$e items e#o0, 0$i$ I $ae si%ne2 'o1 I ea#ise t$at I 0i## not e pemitte2 to 0o 0it$o"t t$em1 I a%ee to 0ea o "se, in t$e pope manne, t$e e3"ipment iss"e2 to me 'o MY sa'et* an2 $ea#t$, as 0e## as t$is ein% a #e%a# e3"iement1 I ea#ise t$at i' I 'ai# to 0ea/"se t$is e3"ipment an2 as a es"#t, I s"stain an in="*, t$e Compensation Commissione 'o O"pationa# In="* an2 Diseases o !EM 0i## e in'ome2 an2 t$is ma* =eopa2ise m* i%$t to ompensation1 +i%ne2 44444444444 itness 44444444444441
DESCRIPTION
Date 44444444444411 Date 4444444441
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Appointment of In2i0ent In3e/tigator form ACCIDENT AND INCIDENT IN*ESTI6ATION INCIDENT IN*ESTI6ATO+ IN TE+MS OF 6A+ $ AND 8 AND SECTION & OF THE OCCUPATIONAL HEALTH AND SAFETY ACT, 8 OF !""# I, 44444444444444442esi%nate2 as t$e 4444444444444 'o 11 4444444444444 2o $ee* 2esi%nate *o" as ACCIDENT/INCIDENT INFE+TIGATOR 0it$ t$e 'o##o0in% 2"ties an2 esponsii#ities6 1 Inesti%ate a## ini2ents an2 ai2ents1 .1 Repot t$e 'in2in%s o' t$e inesti%ation on t$e Anne8"e o (a) 'oms1 71 Ens"e t$at t$e emp#o*e en2oses t$e Anne8"e o (a) 'oms an2 a#so t$e C$aiman o' t$e Hea#t$ an2 +a'et* Committee in tems o' +etion (?)7 GAR1 44444444441144141 +i%nat"e o' CEO/Emp#o*e
11444444444 Date
A22eptan2e I, 444444444444444 $ee* aept t$is 2 esi%nation, "n2estan2 t$e ontents an2 a%ee to omp#*1 444444444444441144141 +i%nat"e
114444 44444444441 Date
Annexure 1: Use this form to record nd in!esti"te incidences Occu#tion$ %e$th nd Sfet& Act' 1(() *Act No+ ,- of 1((). ANNE/URE 1 Re"u$tion , nd ( of the Gener$ Administrti!e Re"u$tions Recordin" nd in!esti"tion of incidents
1. 2. 3.
A+ Recordin" of incident Name of employer …………………………………………………………………………………………… Name of affected person …………………………ID No ………………………………………………………….. Date of incident …………………………………. 4. Time of incident ……………………………………….
5. Part of body affected
6. Effect on person
. E!pected period of disablement ". %.
Head or neck
Eye
Trunk
Finger
Hand
Arm
Foot
Leg
Internal
Multiple
Burns
Amputation
Sprains or strains Contusions or wounds Fractures
!nconscious"ness #oisoning Electric shock Asphyiation + , -. days
(,/ weeks
$ccupational %isease & '( weeks or permanent disa)lement & / , -0 & -0"'( *illed weeks weeks
Description of #cc$pational disease ………………………………………………………………………………………... &ac'ine(process in)ol)ed(type of *or+ performed(e!pos$re ……………………………………………………………… ………………………………………………………………………………………………………… ……………………………………………………………………………………………………… 1,. -as incident reported to t'e ompensation ommissioner/ 0es……………..No……………..ef………………… 11. -as incident reported to P/ 0es ………..No ……………….ef………………………….. 12. -as incident reported to Pro)incial Director/ 0es……….No…………ef…………………….. in case of a 'aardo$s c'emical s$bstance indicate s$bstance e!posed to 0+ In!esti"tion of the o!e incident & #erson desi"nted thereto 1. Name of in)esti7ator ……………………………………… 2. Date of in)esti7ation …………………………… 3. Desi7nation of in)esti7ator ………………………………………………………………………………….. …………………………………………………………………………………………………………………… 4. 'ort description of incident …………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………. 5. $spected ca$se of incident …………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… 6 ecommended steps to pre)ent a rec$rrence ………………………………………………………………………….. …………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………….. ……………………………………. ……………………………………. i7nat$re of in)esti7ator Date 2+ Action t3en & em#$o&er to #re!ent the recurrence of simi$r incident ………………………………………………………………………………………………………………………………………… … ………………………………………………………………………………………………………………………………………… … ………………………………………………………………………………………………………………………………………… … ……………………………………. ……………………………………. i7nat$re of in)esti7ator Date 4+ Remr3s & %e$th nd Sfet& Committee emar+s ……………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………. i7nat$re of 'airman of t'e 8ealt' 9 afety ommittee ……………………………………………………………………… Use this form to record nd in!esti"te in5uries to non6em#$o&ees OCCUPATIONAL HEALTH 4 SAFETY ACT, 8 OF !""# +E6ULATION 8 AND " OF THE 6ENE+AL ADMINIST+ATI*E +E6ULATIONS %ACCIDENTS AFFECTIN6 NONBEMPLOYEES' a
Name an2 I2entit* no o' in="e2 peson 4444444444444444444
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+IGNED6 444444444444414
DATE6 44444444444144411
I $ee* aept t$is Appointment6 +IGNED6 44444444444444444 DATE6 4444444444444144411 A7P%A0ETICA7 7IST %A8ARDOUS C%E9ICA7 SU0STANCES 9A/I9U9 UANTITIES STORED AT AN;
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