Form 4020

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* 1. Name

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* 2. Position

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* 3. Date

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* 4. Worksite/Job Name

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* 5. Date & Time of Accident

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* 6. Please describe what you saw and heard in chronological order

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* 7. What were you doing just before the incident?

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* 8. What were you doing when the incident occurred?

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* 9. What did you do after the incident occurred?

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* 10. What was the condition of the tools, equipment, machinery and materials involved in the incident?

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* 11. What was the type and condition of the Personal Protective Equipment (PPE) being used by the injured person when the incident occurred?

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* 12. What was the instruction or training you and others received like on the task being performed when the incident occurred?  Please describe the training and instruction.

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* 13. Who else witnessed or heard the incident?

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* 14. How do you think we can prevent this incident in the future?

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* 15. Are there any more details you would like to add to your statement?

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* 16. I certify that the above answers are true and accurate to the best of my recollection.

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