Click on the item you are interested in to expand the accordian.
Most of the forms and documents will automatically download to your computer when you click on the link.
Report Form - Complete
COMPLETE INJURY INCIDENT REPORT INVESTIGATION - Word File
COMPLETE INJURY INCIDENT REPORT INVESTIGATION - PDF
Individual Pages
EMPLOYEE REPORT - Word File
SUPERVISOR REPORT - Word File
WITNESS REPORT - Word File
Supporting Documents
INJURY & ILLNESS PROFILE - PDF File
POTENTIAL CAUSE MATRIX - PDF File
PROXIMATE CAUSE TABLE - PDF File
Root Cause Analysis Tools
Cause Map Template
5 WHYS EDUCATION
5 WHYS WORKSHEET - PDF File
FISH BONE ANALYSIS
Confined Space Attendent Training - PDF
Confined Space Hazard Evaluation - PDF
Confined Space Pre-Entry Checklist - Word File
Confined Space Checklist - Word File
Confined Space Checklist - PDF File
Confined Space Decision Flow Chart - PDF File
Confined Space Entry Log - Word File
Confined Space Entry Log - PDF File
Confined Space Entry Permit - Word File
Confined Space Entry Permit - PDF
Crane Activity Info Sheet - PDF
Crane Activity Info Sheet - Word File
Crane Critical Lift Work Sheet - Word File
Crane Lift Site Supervisor Checklist - PDF
Crane Lift Work Sheet - Word File
Crane Operator Daily Inspection - PDF
Crane Operator Daily Inspection - Word File
Crane Regulation Washington - Assigned Duties - PDF
Excavation Inspection - Word File
Excavation Trenching Plan 1 - PDF
Excavation Trenching Plan 2 - PDF
Excavation Trenching Plan 3 - PDF
Use these documents to help determine the appropriate PPE and protocols for stainless steel hot work.
Hex Chrome Exposure Determination - PDF
Hex Chrome Poster - PDF
Fall Protection Inspection Log - Excel File
Fall Protection Inspection Log - PDF File
Ladder Inspection Sheet - PDF File
Ladder Inspection Sheet - Word File
Mobile Equipment Inspection Sheet - Excel File
Mobile Equipment Inspection Sheet - PDF File
Lock Removal Form If a workers lock has been left on a lockbox and must be removed by supervision, this form must be completed.
LOTO request form This form should be completed by Foremen and others who wish to have equipment locked out.
LOTO Log Sheet This form must be used for each locked out piece of equipment to track who is involved in the LOTO.
LOTO Hazardous Energy Survey This form must be used to determine what hazards are present and must be mitigated via LOTO.
Fixed Mast Forklift Performance Evaluation - PDF File
Variable Reach Forklift Performance Evaluation - PDF File
Forklift Written Test - PDF File
Forklift Certificate - PDF File
Manlift Performance Evaluation - PDF File
Manlift Written Test - PDF File
The forms here must be completed by all new employees and those who are being rehired. Ensure that all forms here are completed using BLUE ink. When you print the forms ensure that they are DOUBLE SIDED to reduce physical file size.
Disciplinary Action Form - PDF
Driver Agreement - PDF - Keep this filed on site with the employee records.
Employee Acknowledgement Package - PDF - Keep this filed on site with the employee records.
I-9 Instructions - PDF - This explains the documents required for completing the I-9 form included in the W4 Package.
New Hire Log - PDF - Send this to Bellingham Payroll
Separation Questionnaire - PDF - Send this to Bellingham Payroll
W4 Package for Union Workers - PDF - Send this to Bellingham Payroll
Use this Excel file to plan for effective safety management on a project. This is obviously not a complete and total list of all possible hazards, but using the checklists provided here will give you a good place to start in planning for Best in Class Safety.
Use this link to download posters and publications required by the state your project is located in.
Reporting
On any project affected by USL&H, complete the form LS-202 and ensure it is submitted along with the First Report of Injury required by our workers compensation insurer. That form can be found under the "Workers Compensation" drop down menu.
The time period for reporting to USL&H is 10 days from notice by an injured worker to filing of form LS-202. The deadline is found in 33 U.S.C. § 930(a):
(a)Time for sending; contents; copy to deputy commissioner
Within ten days from the date of any injury, which causes loss of one or more shifts of work, or death or from the date that the employer has knowledge of a disease or infection in respect of such injury, the employer shall send to the Secretary a report setting forth (1) the name, address, and business of the employer; (2) the name, address, and occupation of the employee; (3) the cause and nature of the injury or death; (4) the year, month, day, and hour when and the particular locality where the injury or death occurred; and (5) such other information as the Secretary may require. A copy of such report shall be sent at the same time to the deputy commissioner in the compensation district in which the injury occurred. Notwithstanding the requirements of this subsection, each employer shall keep a record of each and every injury regardless of whether such injury results in the loss of one or more shifts of work.
The 10 days runs from when the employer has notice of the injury and the injury causes loss of one or more shifts of work.
So, if the claimant provides notice more than 10 days after the injury, the deadline is 10 days after notice is provided to the employer.
If the injury does not immediately cause the claimant to miss one or more shifts of work, then the deadline for filing the LS-202 is 10 days from when it first causes loss of 1 or more shifts of work.
If the claimant has an injury or disease that causes him or her to miss work, and the employer only later learns the absence from work was caused by an alleged work-related injury or disease, the 10 day period starts counting from when the employer learns the claimant’s absence from work was due to an allegedly work-related cause.
Form Links Below:
In Washington State, all workers' compensation claims are filed with Labor and Industries. The physician will have the required claim form. Contact Ray Pierce for instructions on the procedure.
Outside Washington State, use the information below to report a workers' compensation claim.
1 - You must collect the information requested on the First Report of Injury Form.
Click here to get the First Report of Injury Form
You will need our policy number. Contact Ray Pierce for assistance.
Liberty Mutual Portal Username and password required.
Phone: 800-362-0000
