SAFETY AND TRAINING MONTHLY REPORT Safety Step 1 of 5 20% Name of Cooperative/Company*ANECBARCCVECChoptankCECCBECDECMECNNECNOVECPVECPGECRECSVECSECReport for the: (month & year)* MM slash DD slash YYYY Total # of Employees*Total # of Hours Worked for Month*# of Non-Lost Time Accidents for Month*(if none, please put 0)Type of Injury-Non-Lost Time* Date-Non-Lost Time* MM slash DD slash YYYY Select:* Add Another Line Done Type of Injury-Non-Lost Time* Date-Non-Lost Time* MM slash DD slash YYYY Select:* Add Another Line Done Type of Injury-Non-Lost Time* Date-Non-Lost Time* MM slash DD slash YYYY # of Lost Time Accidents for Month*(if none, please put 0)Type of Injury-Lost Time* Date-Lost Time* MM slash DD slash YYYY Days Lost for Month*Date Returned to Work MM slash DD slash YYYY Leave blank if not back at workSelect-Time Lost:* Add Another Line Done Type of Injury-Lost Time* Date-Lost TIme* MM slash DD slash YYYY Days Lost for Month*Date Returned to Work MM slash DD slash YYYY Leave blank if not back at workSelect-Time Lost:* Add Another Line Done Type of Injury-Lost Time Date-Lost Time* MM slash DD slash YYYY Days Lost for Month*Date Returned to Work MM slash DD slash YYYY Leave blank if not back at work CARS:__________________________________________________________________________________________________Total # of Cars in Operation*Total # of Car Miles Driven For The Month*Total # of Car Accidents For The Month*(if none, please put 0)Total # of Car Accidents With Injury For The Month*(if none, please put 0)Car Accident Date: MM slash DD slash YYYY Car Accident Details:Select:* Add Another Car Accident Done 2. Car Accident Date: MM slash DD slash YYYY 2. Car Accident Details:3. Select:* Add Another Car Accident Done 3. Car Accident Date: MM slash DD slash YYYY 3. Car Accident Details:4. Select:* Add Another Car Accident Done 4. Car Accident Date: MM slash DD slash YYYY 4. Car Accident Details:5. Select:* Add Another Car Accident Done 5. Car Accident Date: MM slash DD slash YYYY 5. Car Accident Details:Car Accident With Injury Date: MM slash DD slash YYYY Car Accident With Injury Details:Select:* Add Another Car Accident With Injury Done 2. Car Accident With Injury Date: MM slash DD slash YYYY 2. Car Accident With Injury Details:3. Select:* Add Another Car Accident With Injury Done 3. Car Accident With Injury Date: MM slash DD slash YYYY 3. Car Accident With Injury Details:4. Select:* Add Another Car Accident With Injury Done 4. Car Accident With Injury Date: MM slash DD slash YYYY 4. Car Accident With Injury Details:5. Select:* Add Another Car Accident With Injury Done 5. Car Accident With Injury Date: MM slash DD slash YYYY 5. Car Accident With Injury Details: TRUCKS:___________________________________________________________________________________________________Total # of Trucks in Operation* Total # of Truck Miles Driven For The Month*Total # of Truck Accidents For The Month*(if none, please put 0)Total # of Truck Accidents With Injury For The Month*(if none, please put 0)Truck Accident Date: MM slash DD slash YYYY Truck Accident Details:Select: Truck Accident* Add another truck accident Done 2. Truck Accident Date: MM slash DD slash YYYY 2. Truck Accident Details:3. Select: Truck Accident* Add another truck accident Done 3. Truck Accident Date: MM slash DD slash YYYY 3. Truck Accident Details:4. Select: Truck Accident* Add another truck accident Done 4. Truck Accident Date: MM slash DD slash YYYY 4. Truck Accident Details:5. Select: Truck Accident* Add another truck accident Done 5. Truck Accident Date: MM slash DD slash YYYY 5. Truck Accident Details:Truck Accident With Injury Date MM slash DD slash YYYY Truck Accident With Injury Details:Select: Truck Accident With Injury Details Add another truck accident With Injury Details Done Truck Accident With Injury Date MM slash DD slash YYYY Truck Accident With Injury Details:3. Select: Truck Accident With Injury Details Add another truck accident With Injury Details Done 3. Truck Accident With Injury Date MM slash DD slash YYYY 3. Truck Accident With Injury Details:4. Select: Truck Accident With Injury Details Add another truck accident With Injury Details Done 4. Truck Accident With Injury Date MM slash DD slash YYYY 4. Truck Accident With Injury Details:5. Select: Truck Accident With Injury Details Add another truck accident With Injury Details Done 5. Truck Accident With Injury Date MM slash DD slash YYYY 5. Truck Accident With Injury Details: TOTALS: ______________________________________________________________________________________________________________________Cars & Trucks in Operation TotalMiles Driven Cars & Trucks Total# of Accidents Cars & Trucks Total# of Accidents With Injuries Cars & Trucks Total Reported By:* Date* MM slash DD slash YYYY Δ PALMYRA TRAINING CALENDAR SAFETY STAFF ADMIN PAGE Need help? Contact Dirrick Simmons by email or phone: (434) 510-4000.
