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Submission: On June 07 via automatic, source certstream-suspicious — Scanned from DE
Submission: On June 07 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
POST /#wpcf7-f3737-p2155-o1
<form action="/#wpcf7-f3737-p2155-o1" method="post" class="wpcf7-form init" aria-label="Contact form" enctype="multipart/form-data" novalidate="novalidate" data-status="init">
<div style="display: none;">
<input type="hidden" name="_wpcf7" value="3737">
<input type="hidden" name="_wpcf7_version" value="5.7.3">
<input type="hidden" name="_wpcf7_locale" value="en_US">
<input type="hidden" name="_wpcf7_unit_tag" value="wpcf7-f3737-p2155-o1">
<input type="hidden" name="_wpcf7_container_post" value="2155">
<input type="hidden" name="_wpcf7_posted_data_hash" value="">
<input type="hidden" name="_wpcf7cf_hidden_group_fields"
value="["good-near","good-near","what-happened","action-taken","describe-vehicle","incident-location","incident-location","location-other","was-working-vehicle","was-working-vehicle","action-before-accident","location-other","action-before-accident","describe-accident","was-working-person","was-working-person","action-before-injury","leading-factors","equipment-involved","equipment-involved","eq-manufacturer","eq-age","eq-serial","eq-model","eq-function","eq-location","eq-modified","eq-modified","date-modified","eq-guarded","eq-guarded","describe-gaurd","eq-constructed","eq-constructed","eq-installed","eq-installed","eq-adjusted","eq-adjusted","no-above-explain","eq-failiure","eq-failiure","failiure-cause","construction-related","construction-related","date-of-contract","is-firm","is-firm","other-contractors","weather-contributions","training-recieved","training-recieved","type-of-training","intructed-by","when-instructed","length-of-training","ppe-used","ppe-used","type-of-ppe","ppe-failiure","ppe-failiure","describe-ppe-failiure","action-before-injury","eq-manufacturer","eq-age","eq-serial","eq-model","eq-function","eq-location","eq-modified","eq-modified","date-modified","describe-gaurd","eq-constructed","eq-constructed","eq-installed","eq-installed","eq-adjusted","eq-adjusted","no-above-explain","failiure-cause","date-of-contract","is-firm","is-firm","other-contractors","weather-contributions","type-of-training","intructed-by","when-instructed","length-of-training","type-of-ppe","ppe-failiure","ppe-failiure","describe-ppe-failiure","describe-ppe-failiure","seen-medical","seen-medical","physician-name","physician-address","physician-city","physician-state","physician-zip","emergency-room","emergency-room","hospitalized-overnight","hospitalized-overnight","hospital-name","hospital-address","hospital-city","hospital-state","hospital-zip","physician-name","physician-address","physician-city","physician-state","physician-zip","emergency-room","emergency-room","hospital-name","hospital-address","hospital-city","hospital-state","hospital-zip"]">
<input type="hidden" name="_wpcf7cf_hidden_groups"
value="["goodcatch-nearmiss","vehicle-accident","not-premises","was-working","workplace-injury","yes-working-person","yes-equipment-involved","eq-yes-modified","eq-yes-guarded","eq-yes-failiure","yes-construction","yes-training-recieved","yes-ppe-used","yes-ppe-failiure","hospitalized","yes-medical","yes-hospitalized"]">
<input type="hidden" name="_wpcf7cf_visible_groups" value="[]">
<input type="hidden" name="_wpcf7cf_repeaters" value="[]">
<input type="hidden" name="_wpcf7cf_steps" value="{}">
<input type="hidden" name="_wpcf7cf_options"
value="{"form_id":3737,"conditions":[{"then_field":"goodcatch-nearmiss","and_rules":[{"if_field":"report-type","operator":"equals","if_value":"Good Catch \/ Near Miss"}]},{"then_field":"vehicle-accident","and_rules":[{"if_field":"report-type","operator":"equals","if_value":"Vehicle Accident"}]},{"then_field":"workplace-injury","and_rules":[{"if_field":"report-type","operator":"equals","if_value":"Workplace Injury"}]},{"then_field":"hospitalized","and_rules":[{"if_field":"report-type","operator":"equals","if_value":"Vehicle Accident"}]},{"then_field":"hospitalized","and_rules":[{"if_field":"report-type","operator":"equals","if_value":"Workplace Injury"}]},{"then_field":"not-premises","and_rules":[{"if_field":"incident-location","operator":"equals","if_value":"No"}]},{"then_field":"was-working","and_rules":[{"if_field":"was-working-vehicle","operator":"equals","if_value":"Yes"}]},{"then_field":"yes-equipment-involved","and_rules":[{"if_field":"equipment-involved","operator":"equals","if_value":"Yes"}]},{"then_field":"eq-yes-modified","and_rules":[{"if_field":"eq-modified","operator":"equals","if_value":"Yes"}]},{"then_field":"eq-yes-guarded","and_rules":[{"if_field":"eq-guarded","operator":"equals","if_value":"Yes"}]},{"then_field":"eq-yes-failiure","and_rules":[{"if_field":"eq-failiure","operator":"equals","if_value":"Yes"}]},{"then_field":"yes-construction","and_rules":[{"if_field":"construction-related","operator":"equals","if_value":"Yes"}]},{"then_field":"yes-training-recieved","and_rules":[{"if_field":"training-recieved","operator":"equals","if_value":"Yes"}]},{"then_field":"yes-ppe-used","and_rules":[{"if_field":"ppe-used","operator":"equals","if_value":"Yes"}]},{"then_field":"yes-ppe-failiure","and_rules":[{"if_field":"ppe-failiure","operator":"equals","if_value":"Yes"}]},{"then_field":"yes-medical","and_rules":[{"if_field":"seen-medical","operator":"equals","if_value":"Yes"}]},{"then_field":"yes-hospitalized","and_rules":[{"if_field":"hospitalized-overnight","operator":"equals","if_value":"Yes"}]},{"then_field":"yes-working-person","and_rules":[{"if_field":"was-working-person","operator":"equals","if_value":"Yes"}]}],"settings":{"animation":"yes","animation_intime":200,"animation_outtime":200,"conditions_ui":"normal","notice_dismissed":false}}">
</div>
<p><label> First Name (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="first-name"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text" name="first-name"></span> </label>
</p>
<p><label> Last Name (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="last-name"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text" name="last-name"></span> </label>
</p>
<p><label> Which utility are you reporting from? (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="your-recipient"><select class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required" aria-required="true" aria-invalid="false" name="your-recipient">
<option value="">—Please choose an option—</option>
<option value="Test">Test</option>
<option value="Corporate">Corporate</option>
<option value="Blue Topaz Utilities">Blue Topaz Utilities</option>
<option value="Cascadia Water">Cascadia Water</option>
<option value="Falls Water Company">Falls Water Company</option>
<option value="Foothills Utilities">Foothills Utilities</option>
<option value="Gem State Water">Gem State Water</option>
<option value="Salmon Valley Water">Salmon Valley Water</option>
<option value="Suncadia Utilities">Suncadia Utilities</option>
<option value="Sunriver Utilities">Sunriver Utilities</option>
</select></span> </label>
</p>
<p><label> Date of incident (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="date-123"><input class="wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date" aria-required="true" aria-invalid="false" value="2023-06-07" type="date"
name="date-123"></span> </label>
</p>
<p><label> Type of Incident/Report (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="report-type"><select class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required" aria-required="true" aria-invalid="false" name="report-type">
<option value="">—Please choose an option—</option>
<option value="Good Catch / Near Miss">Good Catch / Near Miss</option>
<option value="Vehicle Accident">Vehicle Accident</option>
<option value="Workplace Injury">Workplace Injury</option>
</select></span> </label>
</p>
<div data-id="goodcatch-nearmiss" data-orig_data_id="goodcatch-nearmiss" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<fieldset>
<p>Please refer to the following examples describing “Good Catch / Near Miss” : </p>
<p>What is a Near Miss/Good Catch? </p>
<p>A Near Miss/Good Catch is an unplanned event that had the potential to result in injury, illness, damage or loss, but – luckily – it did not. </p>
<p>What is a Near Miss? </p>
<p>A Near Miss occurs when a series of error-precursors nearly results in an injury, property damage or environmental incident. Examples range from an open hole, distracted drivers, equipment/tool failure to mud-covered steps or iced walkways.
Identifying and mitigating error precursors reduces our risk. </p>
<p>Examples of Near Miss: </p>
<p>⦁ A team member discovered a loose 250-amp breaker when conducting an infrared scan on a panel. </p>
<p>⦁ A team member cut the bands of a wire reel, and the bands’ stored tension nearly hit the team member in the face. </p>
<p>What is a Good Catch? </p>
<p>A Good Catch is when a worker recognizes a hazard or unsafe condition and addresses/removes it before it results in an adverse safety or health outcome. </p>
<p>Examples of Good Catches: </p>
<p>⦁ A team member provided a Peer Check for another team member who was working on a stepladder which was close to coming off the edge of a concrete slab. </p>
<p>⦁ Two team members noticed a hole in the roof above where they were working. They took a STOP/Time-Out and contacted the roofers; the overhead hole was covered and barricaded. </p>
<p>⦁ During an Equipment Inspection, a team member noticed lug nuts missing on a wheel that was still intact. </p>
<p>Benefits of Reporting a Near Miss/Good Catch </p>
<p>The goal is to effectively communicate Near Misses/Good Catches so we can build our capacity to better forecast incident prevention, and limit getting caught in the storm of an injury. Together we must work as a team to report all Near
Misses/Good Catches to help improve jobsite safety and go home safely. </p>
<p><label> Good catch / near miss (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="good-near"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="good-near"
value="Good Catch" tabindex=""><span class="wpcf7-list-item-label">Good Catch</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="good-near" value="Near Miss" tabindex=""><span
class="wpcf7-list-item-label">Near Miss</span></span></span></span> </label>
</p>
<p><label> Give a brief description of the event (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="what-happened"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text" name="what-happened"></span>
</label>
</p>
<p><label> Describe action taken and ways to prevent future incidents (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="action-taken"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text" name="action-taken"></span>
</label>
</p>
</fieldset>
</div>
<div data-id="vehicle-accident" data-orig_data_id="vehicle-accident" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><label> Fully describe the accident.<br>
<span class="wpcf7-form-control-wrap" data-name="describe-vehicle"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="describe-vehicle"></span> </label>
</p>
<p><label> Did accident happen on workplace premises? (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="incident-location"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox"
name="incident-location" value="Yes" tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="incident-location" value="No" tabindex=""><span
class="wpcf7-list-item-label">No</span></span></span></span> </label>
</p>
<div data-id="not-premises" data-orig_data_id="not-premises" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><span class="wpcf7-form-control-wrap" data-name="location-other"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" placeholder="Location of Event" value=""
type="text" name="location-other"></span>
</p>
</div>
<p><label> Was person performing regular job at time of accident? (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="was-working-vehicle"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox"
name="was-working-vehicle" value="Yes" tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="was-working-vehicle" value="No" tabindex=""><span
class="wpcf7-list-item-label">No</span></span></span></span><br>
</label>
</p>
<div data-id="was-working" data-orig_data_id="was-working" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p>Describe activity the person was doing just before the accident <span class="wpcf7-form-control-wrap" data-name="action-before-accident"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true"
aria-invalid="false" value="" type="text" name="action-before-accident"></span>
</p>
</div>
</div>
<div data-id="workplace-injury" data-orig_data_id="workplace-injury" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><label> Fully describe the accident.<br>
<span class="wpcf7-form-control-wrap" data-name="describe-accident"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="describe-accident"></span> </label>
</p>
<p><label> Was person performing regular job at time of accident? (Required)<br>
<span class="wpcf7-form-control-wrap" data-name="was-working-person"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox"
name="was-working-person" value="Yes" tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="was-working-person" value="No" tabindex=""><span
class="wpcf7-list-item-label">No</span></span></span></span><br>
</label>
</p>
<div data-id="yes-working-person" data-orig_data_id="yes-working-person" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p>Describe activity the person was doing just before the accident <span class="wpcf7-form-control-wrap" data-name="action-before-injury"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true"
aria-invalid="false" value="" type="text" name="action-before-injury"></span>
</p>
</div>
<p><label> What factors led to the accident?<br>
<span class="wpcf7-form-control-wrap" data-name="leading-factors"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="leading-factors"></span> </label>
</p>
<p><label> Was there machinery / equipment involved in the injury?<br>
<span class="wpcf7-form-control-wrap" data-name="equipment-involved"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox"
name="equipment-involved" value="Yes" tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="equipment-involved" value="No" tabindex=""><span
class="wpcf7-list-item-label">No</span></span></span></span> </label>
</p>
<div data-id="yes-equipment-involved" data-orig_data_id="yes-equipment-involved" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><span class="wpcf7-form-control-wrap" data-name="eq-manufacturer"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Manufacturer" value="" type="text" name="eq-manufacturer"></span><br>
<span class="wpcf7-form-control-wrap" data-name="eq-age"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Equipment age" value="" type="text" name="eq-age"></span><br>
<span class="wpcf7-form-control-wrap" data-name="eq-serial"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Equipment Serial No." value="" type="text" name="eq-serial"></span><br>
<span class="wpcf7-form-control-wrap" data-name="eq-model"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Model" value="" type="text" name="eq-model"></span><br>
<span class="wpcf7-form-control-wrap" data-name="eq-function"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Equipment Function" value="" type="text" name="eq-function"></span><br>
<span class="wpcf7-form-control-wrap" data-name="eq-location"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Equipment Location" value="" type="text" name="eq-location"></span><br>
<label>Has machine/equipment been modified?<br>
<span class="wpcf7-form-control-wrap" data-name="eq-modified"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="eq-modified"
value="Yes" tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="eq-modified" value="No" tabindex=""><span
class="wpcf7-list-item-label">No</span></span></span></span> </label>
</p>
</div>
<div data-id="eq-yes-modified" data-orig_data_id="eq-yes-modified" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><span class="wpcf7-form-control-wrap" data-name="date-modified"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="When was it modified?" value="" type="text" name="date-modified"></span>
</p>
</div>
<p><label> Was equipment guarded?<br>
<span class="wpcf7-form-control-wrap" data-name="eq-guarded"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="eq-guarded" value="Yes" tabindex=""><span
class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="eq-guarded" value="No" tabindex=""><span class="wpcf7-list-item-label">No</span></span></span></span> </label>
</p>
<div data-id="eq-yes-guarded" data-orig_data_id="eq-yes-guarded" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><label> describe guarding and how it functions to provide element of safety desired<br>
<span class="wpcf7-form-control-wrap" data-name="describe-gaurd"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="describe-gaurd"></span> </label><br>
<label> Constructed?<br>
<span class="wpcf7-form-control-wrap" data-name="eq-constructed"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="eq-constructed" value="Yes"
tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="eq-constructed" value="No" tabindex=""><span
class="wpcf7-list-item-label">No</span></span></span></span> </label><br>
<label> Installed?<br>
<span class="wpcf7-form-control-wrap" data-name="eq-installed"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="eq-installed" value="Yes"
tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="eq-installed" value="No" tabindex=""><span class="wpcf7-list-item-label">No</span></span></span></span>
</label><br>
<label> Adjusted?<br>
<span class="wpcf7-form-control-wrap" data-name="eq-adjusted"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="eq-adjusted" value="Yes"
tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="eq-adjusted" value="No" tabindex=""><span class="wpcf7-list-item-label">No</span></span></span></span>
</label>
</p>
<p><label> If no to any of the above, explain.<br>
<span class="wpcf7-form-control-wrap" data-name="no-above-explain"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="no-above-explain"></span> </label>
</p>
</div>
<p><label> Was there any mechanical failiure?<br>
<span class="wpcf7-form-control-wrap" data-name="eq-failiure"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="eq-failiure" value="Yes" tabindex=""><span
class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="eq-failiure" value="No" tabindex=""><span class="wpcf7-list-item-label">No</span></span></span></span> </label>
</p>
<div data-id="eq-yes-failiure" data-orig_data_id="eq-yes-failiure" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><label> Explain failiure and cause:<br>
<span class="wpcf7-form-control-wrap" data-name="failiure-cause"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="failiure-cause"></span> </label>
</p>
</div>
<p><label> Was the incident construction related?<br>
<span class="wpcf7-form-control-wrap" data-name="construction-related"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="construction-related" value="Yes"
tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="construction-related" value="No" tabindex=""><span
class="wpcf7-list-item-label">No</span></span></span></span> </label>
</p>
<div data-id="yes-construction" data-orig_data_id="yes-construction" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><label> Date of contract:<br>
<span class="wpcf7-form-control-wrap" data-name="date-of-contract"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="date-of-contract"></span> </label><br>
<span class="wpcf7-form-control-wrap" data-name="is-firm"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="is-firm" value="General Contractor"
tabindex=""><span class="wpcf7-list-item-label">General Contractor</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="is-firm" value="Subcontractor" tabindex=""><span
class="wpcf7-list-item-label">Subcontractor</span></span></span></span><br>
<label> List names of other contractors:<br>
<span class="wpcf7-form-control-wrap" data-name="other-contractors"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="other-contractors"></span> </label><br>
<label> List any weather conditions that contrinbuted to the incident:<br>
<span class="wpcf7-form-control-wrap" data-name="weather-contributions"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="weather-contributions"></span> </label>
</p>
</div>
<p><label> Did employee receive specific training or instructions relating to safety and health on the job being performed?<br>
<span class="wpcf7-form-control-wrap" data-name="training-recieved"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="training-recieved" value="Yes"
tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="training-recieved" value="No" tabindex=""><span
class="wpcf7-list-item-label">No</span></span></span></span> </label>
</p>
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<p><span class="wpcf7-form-control-wrap" data-name="type-of-training"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Type of training" value="" type="text" name="type-of-training"></span><br>
<span class="wpcf7-form-control-wrap" data-name="intructed-by"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Instructed by" value="" type="text" name="intructed-by"></span><br>
<span class="wpcf7-form-control-wrap" data-name="when-instructed"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="When instructed" value="" type="text" name="when-instructed"></span><br>
<span class="wpcf7-form-control-wrap" data-name="length-of-training"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Length of training" value="" type="text" name="length-of-training"></span>
</p>
</div>
<p><label> Did employee use any personal protective equipment (PPE) for the job or task performed?<br>
<span class="wpcf7-form-control-wrap" data-name="ppe-used"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="ppe-used" value="Yes" tabindex=""><span
class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="ppe-used" value="No" tabindex=""><span class="wpcf7-list-item-label">No</span></span></span></span> </label>
</p>
<div data-id="yes-ppe-used" data-orig_data_id="yes-ppe-used" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><span class="wpcf7-form-control-wrap" data-name="type-of-ppe"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Type(s) of PPE" value="" type="text" name="type-of-ppe"></span><br>
<label> Did equipment fail?<br>
<span class="wpcf7-form-control-wrap" data-name="ppe-failiure"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="ppe-failiure" value="Yes"
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</label>
</p>
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<p><span class="wpcf7-form-control-wrap" data-name="describe-ppe-failiure"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Describe failiure" value="" type="text" name="describe-ppe-failiure"></span>
</p>
</div>
</div>
</div>
<div data-id="hospitalized" data-orig_data_id="hospitalized" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><label> Was employee seen or treated by a medical professional?<br>
<span class="wpcf7-form-control-wrap" data-name="seen-medical"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="seen-medical" value="Yes"
tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="seen-medical" value="No" tabindex=""><span class="wpcf7-list-item-label">No</span></span></span></span>
</label>
</p>
<div data-id="yes-medical" data-orig_data_id="yes-medical" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><span class="wpcf7-form-control-wrap" data-name="physician-name"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Name of physician" value="" type="text" name="physician-name"></span><br>
<span class="wpcf7-form-control-wrap" data-name="physician-address"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Address of physician" value="" type="text" name="physician-address"></span><br>
<span class="wpcf7-form-control-wrap" data-name="physician-city"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="City" value="" type="text" name="physician-city"></span><br>
<span class="wpcf7-form-control-wrap" data-name="physician-state"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="State" value="" type="text" name="physician-state"></span><br>
<span class="wpcf7-form-control-wrap" data-name="physician-zip"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Zip" value="" type="text" name="physician-zip"></span>
</p>
<p><label> Was employee treated in an emergency room?<br>
<span class="wpcf7-form-control-wrap" data-name="emergency-room"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="emergency-room" value="Yes"
tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="emergency-room" value="No" tabindex=""><span
class="wpcf7-list-item-label">No</span></span></span></span> </label>
</p>
</div>
<p><label> Was employee hospitalized overnight?<br>
<span class="wpcf7-form-control-wrap" data-name="hospitalized-overnight"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="hospitalized-overnight"
value="Yes" tabindex=""><span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="hospitalized-overnight" value="No" tabindex=""><span
class="wpcf7-list-item-label">No</span></span></span></span> </label>
</p>
<div data-id="yes-hospitalized" data-orig_data_id="yes-hospitalized" data-class="wpcf7cf_group" style="height: auto;" class="wpcf7cf-hidden">
<p><span class="wpcf7-form-control-wrap" data-name="hospital-name"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Hospital name" value="" type="text" name="hospital-name"></span><br>
<span class="wpcf7-form-control-wrap" data-name="hospital-address"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Hospital address" value="" type="text" name="hospital-address"></span><br>
<span class="wpcf7-form-control-wrap" data-name="hospital-city"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="City" value="" type="text" name="hospital-city"></span><br>
<span class="wpcf7-form-control-wrap" data-name="hospital-state"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="State" value="" type="text" name="hospital-state"></span><br>
<span class="wpcf7-form-control-wrap" data-name="hospital-zip"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Zip" value="" type="text" name="hospital-zip"></span>
</p>
</div>
</div>
<p><label> Attatch any files or photos related to the incident. (Optional)<br>
<span class="wpcf7-form-control-wrap" data-name="add-file"><input size="40" class="wpcf7-form-control wpcf7-file" accept="audio/*,video/*,image/*" aria-invalid="false" type="file" name="add-file"></span> </label><br>
<label> Add any additional comments. (Optional)<br>
<span class="wpcf7-form-control-wrap" data-name="additional-comments"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="additional-comments"></span> </label>
</p>
<p><input class="wpcf7-form-control has-spinner wpcf7-submit" type="submit" value="Submit"><span class="wpcf7-spinner"></span>
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document.getElementById("ak_js_1").setAttribute("value", (new Date()).getTime());
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</form>Text Content
Skip to content Main Menu * Dashboard * Our CompanyMenu Toggle * Blue Topaz Utilities * Cascadia Water * Falls Water Company * Foothills Utilities * Gem State Water * Salmon Valley Water * Suncadia Utilities * Sunriver Utilities * Help ACCIDENT, INCIDENT, OR NEAR MISS REPORT The goal of this survey is to effectively communicate Near Misses/Good Catches so we can build our capacity to better forecast incident prevention, and limit getting caught in the storm of an injury. Together we must work as a team to report all Near Misses/Good Catches to help improve jobsite safety and go home safely. First Name (Required) Last Name (Required) Which utility are you reporting from? (Required) —Please choose an option—TestCorporateBlue Topaz UtilitiesCascadia WaterFalls Water CompanyFoothills UtilitiesGem State WaterSalmon Valley WaterSuncadia UtilitiesSunriver Utilities Date of incident (Required) Type of Incident/Report (Required) —Please choose an option—Good Catch / Near MissVehicle AccidentWorkplace Injury Please refer to the following examples describing “Good Catch / Near Miss” : What is a Near Miss/Good Catch? A Near Miss/Good Catch is an unplanned event that had the potential to result in injury, illness, damage or loss, but – luckily – it did not. What is a Near Miss? A Near Miss occurs when a series of error-precursors nearly results in an injury, property damage or environmental incident. Examples range from an open hole, distracted drivers, equipment/tool failure to mud-covered steps or iced walkways. Identifying and mitigating error precursors reduces our risk. Examples of Near Miss: ⦁ A team member discovered a loose 250-amp breaker when conducting an infrared scan on a panel. ⦁ A team member cut the bands of a wire reel, and the bands’ stored tension nearly hit the team member in the face. What is a Good Catch? A Good Catch is when a worker recognizes a hazard or unsafe condition and addresses/removes it before it results in an adverse safety or health outcome. Examples of Good Catches: ⦁ A team member provided a Peer Check for another team member who was working on a stepladder which was close to coming off the edge of a concrete slab. ⦁ Two team members noticed a hole in the roof above where they were working. They took a STOP/Time-Out and contacted the roofers; the overhead hole was covered and barricaded. ⦁ During an Equipment Inspection, a team member noticed lug nuts missing on a wheel that was still intact. Benefits of Reporting a Near Miss/Good Catch The goal is to effectively communicate Near Misses/Good Catches so we can build our capacity to better forecast incident prevention, and limit getting caught in the storm of an injury. Together we must work as a team to report all Near Misses/Good Catches to help improve jobsite safety and go home safely. Good catch / near miss (Required) Good CatchNear Miss Give a brief description of the event (Required) Describe action taken and ways to prevent future incidents (Required) Fully describe the accident. Did accident happen on workplace premises? (Required) YesNo Was person performing regular job at time of accident? (Required) YesNo Describe activity the person was doing just before the accident Fully describe the accident. Was person performing regular job at time of accident? (Required) YesNo Describe activity the person was doing just before the accident What factors led to the accident? Was there machinery / equipment involved in the injury? YesNo Has machine/equipment been modified? YesNo Was equipment guarded? YesNo describe guarding and how it functions to provide element of safety desired Constructed? YesNo Installed? YesNo Adjusted? YesNo If no to any of the above, explain. Was there any mechanical failiure? YesNo Explain failiure and cause: Was the incident construction related? YesNo Date of contract: General ContractorSubcontractor List names of other contractors: List any weather conditions that contrinbuted to the incident: Did employee receive specific training or instructions relating to safety and health on the job being performed? YesNo Did employee use any personal protective equipment (PPE) for the job or task performed? YesNo Did equipment fail? YesNo Was employee seen or treated by a medical professional? YesNo Was employee treated in an emergency room? YesNo Was employee hospitalized overnight? YesNo Attatch any files or photos related to the incident. (Optional) Add any additional comments. (Optional) Δ NEED HELP OR HAVE QUESTIONS ABOUT THIS FORM? Deborah Davis | Human Resources & Safety deborah.davis@nwnatural.com Darian Osiadacz | Safety Chair dosiadacz@suncadiautilities.com * Dashboard * Our Company * Blue Topaz Utilities * Cascadia Water * Falls Water Company * Foothills Utilities * Gem State Water * Salmon Valley Water * Suncadia Utilities * Sunriver Utilities * Help Copyright © 2023 NW Natural Water. All rights reserved.