LVM Incident Reports

Lago Verde Mine Incident Reports

Incident Report All Reports need to be within 24 hours

* Indicates required field

Name of person involved *

First

Last

Email *

Phone Number *

Date of Incident (must reported to OSHA within 24 hours) *

At what time did this incident occur. Please specify AM or PM *

Job Site Address *

Line 1

Line 2

City

State

Zip Code

Country

Job Name *

Job Site Address *

Occupation or Title of Employee *

Names of Competent Person(s)/Supervisor *

Have you completed OSHA Form 301 *

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) *

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) *

Description of Injury (if applicable) *

Action Taken *

Did you know that you are to immediately contact Pate Clements at the office immediately following an accident or work related injury or illness? *

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? *

What could have been done to prevent this incident or injury? *

Submit photo of the incident *

Max file size: 20MB

Photo 2 (Optional) *

Max file size: 20MB

Submit

Lago Verde Mine Incident Reports

Incident Report ** All Reports need to be within 24 hours**

Incident Report All Reports need to be within 24 hours