WORKPLACE INJURY AND INCIDENT REPORT Company: Company Name: RL Construction Company Company Representative's Name: Robert D.

Mackabee Company Representative's Title: Human Resources Manager Company Name: RL Construction Company Company Address: 440 Montgomery St. San Francisco, California, 94103 Employee: Employee's Name: Peter R. Olsen Employee's Title: Project Management Engineer Employee's Department: Engineering Employee's ID Number: 123456789 Company Name: RL Construction Company Employee's Address: 123 Main St. Mill Valley, California, 94941 Employee Gender: Male Date of Birth: March 15, 1977 Date of Hire: April 03, 2009 Incident Details: Incident Case Number: 123456 Date of Incident: May 04, 2012 Time of Incident: Time cannot be determined Employee's Workday Start Time: 9:00 AM Incident Investigation Date and Time: May 04, 2012 2:00 PM Events Leading Up To the Incident: Employee was inspecting the work site, and making sure that all workers were performing their duties. Details of the Incident: A piece of steel reinforcing bar fell off of the project building's frame, from a height of approximately 30 feet, and struck the employee's right leg. The Results of the Incident: Employee sustained one vertical laceration to his right leg of a length of six inches. Objects or Substances involved in the incident: Steel Reinforcing Bar Medical Treatment Required: The employee was taken to the emergency room and was not

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hospitalized overnight. Physician's Name: Dr. Martin Appenrodt Medical Facility Name: San Francisco General Hospital Medical Facility Address: 450 Medical Drive San Francisco, California, 94103 I cannot determine the number of days absent as the employee is still absent due to this incident.

Report Completed By:

_________________________________________ Donald J. Peters Safety Manager

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