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REGULATION FOR COORDINATION OF ACTIVITIES ON WIND FARM Version 01: 20/10/06

ANALYSIS AND INVESTIGATION OF ACCIDENTS AND Page 1 of 1

WORK-RELATED ILLNESSES FORM Form RCA-12

CONTRACTOR INFORMATION:
COMPANY NAME:

Contracted by:

PERSON SUFFERING THE ACCIDENT:


Name of employee:

Occupation:

INFORMATION REGARDING THE INCIDENT:


Date of incident: Day of the week: Time:
Location of
incident:
Task being performed at moment of incident:
Names of possible witnesses:
Consequences:
Incident
Accident without Sick Leave Description of injuries to persons:
Accident with Sick Leave
Work-related Illness
Accident Description of damage to things:

Detailed description of the incident:

POSSIBLE CAUSES OF THE INCIDENT:


o

PREVENTIVE ACTIONS PROPOSED:


o

At on of ,

Signed by The representative of the


Contractor, Subcontractor or Freelance
Worker:

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