ACCIDENT INVESTIGATION POLICY AND FORMS

OUR GOAL IS ZERO INJURIES IN THE WORKPLACE

REVISED 10/12/17

Accident reporting by employees and associates of Climate Engineers, Inc. is the key to eliminating possibilityof injury to employees and property loss. Learning from past accidents is one of the key elements in accidentprevention. This safety program component addresses the importance of reporting all accidents, work relatedinjuries, and near miss incidents. It is the responsibility of Climate Engineers, Inc. and it’s employees to reportall work related accidents, injuries, and near miss injuries as soon as possible but no later than 24 hours afterthe incident.

Accident investigation forms/statements must be filled out by the injured employee, foreman or anywitness to the accident. Please follow the instructions listed below to ensure that the investigation processwill be performed accurately and efficiently.

1. Employee immediately reports all incidents to Supervisor or Site Foreman.a. REPORT ALL INJURIES!! If injury requires routine job site first aid, treat injury and then fill out

accident investigation form. ALL injuries must be recorded and be recorded within 24 hours ofthe incident. Anything considered “small” could lead to something “BIG” if not properly caredfor.

2. If medical treatment is needed beyond regular first aid and is life threatening, call 911. If medicaltreatment is needed beyond first aid but not life threatening, the supervisor/site foreman will drive orappoint an approved Climate Engineers employee to take the injured employee to an emergency careclinic/emergency room. Under NO circumstances should an injured employee be allowed to drivethemselves to the emergency care clinic or emergency room. If the injury is eye related, do not go tothe emergency room; first seek one of the occupational clinics and then only seek the emergency roomif all other facilities are closed. The below locations are the Climate Engineers preferred locations:

Climate Engineers Cedar Rapids: St. Luke’s Hospital in Cedar Rapids is our emergency employercontact as well as St. Luke’s Work Well Clinic. Severe or Life Threatening injuries will require a 911 call.

St. Luke's Work Well Solutions St. Luke's Hospital830 1st Ave NE 1026 A Ave NECedar Rapids, Iowa 52402 Cedar Rapids, Iowa319-369-8153 319-369-7211

Climate Engineers Eldridge: Genesis Occupational Health in Davenport, Bettendorf, or Moline is ouremergency employer contact. Please use whichever one is closer to the accident location. Severe orLife Threatening injuries will require a 911 call.

DAVENPORT1520 West 53rd St.,Suite 2Davenport, IA 52806(563) 421-3801

BETTENDORF2140 53rd AvenueBettendorf, IA 52722(563) 421-5700

MOLINE2526 41st StMoline, IL 61265(309) 281-2700

ACCIDENT INVESTIGATION POLICY AND FORMS

OUR GOAL IS ZERO INJURIES IN THE WORKPLACE

REVISED 10/12/17

3. If an injury requires a trip to the emergency care clinic/emergency room, inform the clinic that ClimateEngineers has a light duty-return to work program. Additionally, request a return to work form fromthe doctor. A return to work form is required before any injured employee is allowed to return towork.

4. Site Foreman/designated Climate Employee must wait for the injured party to be treated or have aphone available to be reached in order to return to the clinic/emergency room to pick up the injuredemployee.

5. ALL calls to 911 needs to be documented and the Safety Manager needs to be called within the hour ofthe accident/injury.

6. After treatment, the injured employee completes the Employee’s Accident/Incident InvestigationForm. Foreman must fill out the Supervisor’s Investigation Form, and if there were any Witnesses tothe accident, they must fill out the Witness Statement form. Within this form the Employee,Supervisor & Witness, need to thoroughly communicate what caused the accident and how theincident happened. Please use your camera phone to photo the area, equipment, etc. that will assist incommunicating your reporting. Once complete, the forms & all other details need to be turned in tothe Safety Manager at Climate’s office within 24 hours of the accident (or fax/email forms if job site isout of town).

7. Once the employee has been treated and all paperwork completed, a final Employee Review will bescheduled to determine how to prevent this occurrence from happening to others. This informationwill be reviewed by the Safety Committee to determine any further required actions. Once fullyinvestigated, a Tool Box Talk will go out to all employees informing awareness and prevention. Allpersonal information will remain private and held on file by the Safety Manager or Human Resources.

8. When applicable, a Return to Work program will be used for injured employees not able to work 100%their ability. This program will be determined by the Safety Manager’s review of the Doctor’s reports.Return to Work duties include, but not limited to: clerical work, light duty-delivery, material handling,shop cleaning, etc.

EMPLOYEE ACCIDENT INVESTIGATION REPORT

OUR GOAL IS ZERO INJURIES IN THE WORKPLACE Rev. 10/9/17

EMPLOYEE PERSONAL INFORMATION

INCIDENT INFORMATION

Please check all that apply: No Injury/1st aid (notify only) Work Injury Home Injury (non work related) *NOTE: Work injury means injury happened while performing tasks as part of employment at Climate Engineers. Home injury means injury was not sustained

while performing tasks for Climate Engineers but on own personal time.

This form should be completed by the employee & submitted to the Safety Manager as soon as possible after an injury.

Claim Number:

Employee’s Name: ______________________________________________________ Male Female Last First Middle Initial Home Address:

City: _______________________ State: ___________ Zip: _________ Home Phone:

SS#: ______________________ Date of Birth: Climate Engineers Start Date:

Date the injury was reported to management: Time Reported: AM PM

Who in management was the injury reported to: Last First

Location of Incident: Name and Address of Building or Site Area Location

Date of Incident: ___________________________ Time of Incident: _____________ AM PM

Description of accident/incident or employee’s account, including sequence of events preceding the accident? What machine or tool? What operation? (continue on reverse side if necessary):

Wearing Proper Personal Protection Equipment? List all PPE being worn during time of incident:

Nature & Extent of injury/illness (be specific about what parts of the body and condition ex: right eye, left shoulder, strain, rash, cut, etc):

Recommendation on how t prevent a future occurrence of the adverse event? (continue on reverse side if necessary):

Any Witnesses present during incident?: NA Yes, list name(s) No ATTACH WITNESS(S) REPORT(S)

Name of Supervisor/Site Foreman: NA

Last First

Does the Supervisor/Site Foreman agree to above listed details? NA Yes No (if checked no, supervisor to fill out

separate supervisor’s report of incident)

Did you Report this incident to Office: Safety Manager? NA Yes, When? No Date and Time

__________________________________ __________________________ ______________________ Employee Name Printed Employee Signature Date of this Report

WITNESS INCIDENT

INVESTIGATION REPORT

OUR GOAL IS ZERO INJURIES IN THE WORKPLACE

REVISED 10.11.17

Injured or Affected Employee’s Name: ________________________________________________________ Last First Name of Witness: Job Title of Witness Last First M.I. Home Address of Witness:

City: State: Zip: Phone: Witness length of employment at Climate Engineers:

Location of Incident: Name and Address of Building or Site Area Location

Date of Incident: Time of Incident: AM PM

Date the incident was reported to management: Time Reported: AM PM Who in management was the incident reported to: Last First Did the incident occur while the injured/affected employee was performing work as part of employment at Climate Engineers? Yes, explain No, explain

Describe fully the accident/incident including sequence of events preceding the accident? What machine or tool? What operation? (continue on reverse side if necessary):

Wearing Proper Personal Protection Equipment? List all PPE being worn during time of incident:

Nature & Extent of injury/illness (be specific about what parts of the body and condition ex: right eye, left shoulder, strain, rash, cut, etc):

Recommendation on how to prevent a future occurrence of the adverse event? (continue on reverse side if necessary):

Name of Supervisor/Site Foreman: NA

Last First

Does the Supervisor/Site Foreman agree to above listed details? NA Yes No (if checked no, supervisor to fill out separate

supervisor’s report of incident)

Did you Report this incident to Office: Safety Manager? NA Yes, When? No Date and Time

Witness Name Printed Witness Signature Date of this Report

SUPERVISOR’S INCIDENT

INVESTIGATION REPORT

Other Responsible Administrative Official

OUR GOAL IS ZERO INJURIES IN THE WORKPLACE Revision 10/11/17

Incident being reported as: No Injury/1st aid (notify only) Work Injury Home Injury (non work related)

PERSONAL INFORMATION Injured Employee’s Name: Non-Employee Employee Male Female

Job Title/ Occupation: INCIDENT INFORMATION Date of Accident: Time of Accident: AM PM

Date Reported to Management: Time Reported to Management: AM PM

Who in management was the injury reported to:

Incident Occurred on Employer’s Premises? No Yes, list site and location:

Incident Occurred on a Jobsite? No Yes, list site and location: How long has employee worked at site where injury occurred:

Any Witnesses present during incident?: NA No Yes, list name(s) attach witness report(s) Description of accident/incident including sequence of events preceding the accident? What machine or tool? What operation? (continue on reverse side if necessary):

Body part that was affected? Be specific (ex: right eye, left shoulder, index finger, etc):

Nature and extent of injury/illness? Be specific (ex: strain, cut, irritation, etc):

What was the required Personal Protection Equipment needed to performed this job safely?:

Was employee wearing all required PPE?NA Yes No, list what ppe was missing:

Was the employee cautioned for failure to use personal protective equipment/proper safety procedures? NA No Yes, describe:

PLEASE INDICATE ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS

Contributing Factors and Activities Supervisors Preventative Actions to prevent this

from occurring in the future Employee Equipment Require personal protective equipment Not paying attention Equipment failure Retrain employee in proper procedures Unbalanced or poor position or

motion, Ergonomics Improper equipment or material used

for job Develop/revise safety policies/procedures; and/or

update plan Not aware of surroundings Failure to lockout Remove equipment from use and repair or replace Operating without authority Failure to secure Maintain housekeeping and sanitary conditions Going too fast Inoperative Safety Device Address behavior and attitude Taking short cuts Improper grounding Address employee work practices Disregard for safety rules Training/Experience Inform employee to slow down Horseplay Lack of training Other- Explain: Not reporting in a timely manner Safety training provided, not followed Employee fatigue,

mental/physical impairment New task for employee or lack of

experience/skill

Other unsafe practice Work area set up improperly Environmental factors Improper Instruction given to EE Rain Snow Hail Sleet Other Contributing Factor – Explain: Poor Housekeeping Other:

Supervisors Name (Printed) Supervisors Signature Date

POST INCIDENT INVESTIGATION

OUR GOAL IS ZERO INJURIES IN THE WORKPLACE Revised 10.11.17

After an accident, incident or near miss; it is company procedure to follow up the occurrence with a meeting involving the Employee, Supervisor on an as needed basis, and the Safety Manager to discuss the following topics: 1. Review the accident/injury/NM – determine factors that lead to incident: what happened; how/why happened; was proper procedures, equipment, and PPE used? 2. Could this incident been avoided? 3. What can be corrected, moving forward, to prevent a future occurrence of the adverse event? Date of Accident/Incident/Nm Occurrence: Name of Employee with Accident/Incident/NM: Employee Past Incidents: _______________ _________________________ __________________________ _____________________________________________________________________________ Signature of the Employee: _________________________ Date: _______________ Name of Supervisor: Signature of the Supervisor: Date: _______________ Name of Safety Manager: Signature of the Safety Manager: Date: _______________

RETURN TO WORK FORM

OUR GOAL IS ZERO INJURIES IN THE WORKPLACE Revised 10/6/17

Part 1: Self-Certification (to be completed by employee on the first day back after a workplace or home related injury)

Employee Name: Job Title:

1st Day of Absence:

Date Returned to Work:

Returning to work with Restrictions? Yes (attach documentation) No

State briefly why you were unable to perform 100% of your work duties (specify nature of illness or injury, example:

torn ligament, hip fracture, etc. Words like “illness” or “unwell” are not specific enough):

I reported my absence to: on (date): Signed (employee): ………………………………………… Date: ……………………. Part 2: Return To Work Discussion (to be completed by manager with the employee who is returning to work)

Manager’s Name:

Date of Return To Work Discussion:

Has the necessary medical certification been presented? (doctor’s

release notes, doctor’s restrictions note, etc)

NA Yes, ensure to attach to this document

No, collect additional documentation

Summary of discussion:

Any other comments or issues raised, and any further action agreed:

Signed (employee): ………………………………………… Date: ……………………. Signed (manager): ………………………………………… Date: …………………….