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Lago Verde Mine Incident Reports
Incident Report ** All Reports need to be within 24 hours**
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Indicates required field
Name of person involved
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First
Last
Email
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Phone Number
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Date of Incident (must reported to OSHA within 24 hours)
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At what time did this incident occur. Please specify AM or PM
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Job Site Address
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Line 1
Line 2
City
State
Zip Code
Country
Job Name
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Job Site Address
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Occupation or Title of Employee
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Names of Competent Person(s)/Supervisor
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Have you completed OSHA Form 301
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Yes, I have completed the OSHA 301 form
No, I have NOT completed OSHA report, it was not applicable for this incident
Did you know that a Safety Manager, is to interview the employee involved in an incident/injury within 24 hours and must fill out LVM employee's report of injury form (9 pages)
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Yes, an interview has been set up between the employee and the safety manager
No, but I will follow up with the safety manager to ensure an interview has been set up within 24 hours
LIST Description of Incident | Include Location, time, date and location WITHIN the job site (sample: the northwest corner of property by the dumpster pad)
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Description of Injury (if applicable)
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Action Taken
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Did you know that you are to immediately contact Pate Clements at the office immediately following an accident or work related injury or illness?
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Yes, I have already contacted the office
No, but I will now!
A drug test at BayCare Health Facility must be done following a work related accident, injury, or illness. Have you requested a drug screen within 24 hour of the incident?
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Yes, I have obtained a workman's comp claim number
No, but I will now!
What could have been done to prevent this incident or injury?
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Submit photo of the incident
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Max file size: 20MB
Photo 2 (Optional)
*
Max file size: 20MB
Submit
Home
About
Contact
Pricing & Forms
StormTech Rock
LVM Careers
Employee Portal
LVM 90 Day | Annual Review
Termination Paperwork
LVM Incident Reports