SAFETY AND TRAINING MONTHLY REPORT Safety Step 1 of 6 16% Name of Cooperative/Company*Report for the: (month & year)* Date Format: 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* Date Format: MM slash DD slash YYYY Select:*Add Another LineDoneType of Injury-Non-Lost Time*Date-Non-Lost Time* Date Format: MM slash DD slash YYYY Select:*Add Another LineDoneType of Injury-Non-Lost Time*Date-Non-Lost Time* Date Format: MM slash DD slash YYYY # of Lost Time Accidents for Month*(if none, please put 0)Type of Injury-Lost Time*Date-Lost Time* Date Format: MM slash DD slash YYYY Days Lost for Month*Date Returned to Work* Date Format: MM slash DD slash YYYY Select-Time Lost:*Add Another LineDoneType of Injury-Lost Time*Date-Lost TIme* Date Format: MM slash DD slash YYYY Days Lost for Month*Date Returned to Work* Date Format: MM slash DD slash YYYY Select-Time Lost:*Add Another LineDoneType of Injury-Lost TimeDate-Lost Time* Date Format: MM slash DD slash YYYY Days Lost for Month*Date Returned to Work* Date Format: MM slash DD slash YYYY 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: Date Format: MM slash DD slash YYYY Car Accident Details:Select:*Add Another Car AccidentDone2. Car Accident Date: Date Format: MM slash DD slash YYYY 2. Car Accident Details:3. Select:*Add Another Car AccidentDone3. Car Accident Date: Date Format: MM slash DD slash YYYY 3. Car Accident Details:4. Select:*Add Another Car AccidentDone4. Car Accident Date: Date Format: MM slash DD slash YYYY 4. Car Accident Details:5. Select:*Add Another Car AccidentDone5. Car Accident Date: Date Format: MM slash DD slash YYYY 5. Car Accident Details:Car Accident With Injury Date: Date Format: MM slash DD slash YYYY Car Accident With Injury Details:Select:*Add Another Car Accident With InjuryDone2. Car Accident With Injury Date: Date Format: MM slash DD slash YYYY 2. Car Accident With Injury Details:3. Select:*Add Another Car Accident With InjuryDone3. Car Accident With Injury Date: Date Format: MM slash DD slash YYYY 3. Car Accident With Injury Details:4. Select:*Add Another Car Accident With InjuryDone4. Car Accident With Injury Date: Date Format: MM slash DD slash YYYY 4. Car Accident With Injury Details:5. Select:*Add Another Car Accident With InjuryDone5. Car Accident With Injury Date: Date Format: 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: Date Format: MM slash DD slash YYYY Truck Accident Details:Select: Truck Accident*Add another truck accidentDone2. Truck Accident Date: Date Format: MM slash DD slash YYYY 2. Truck Accident Details:3. Select: Truck Accident*Add another truck accidentDone3. Truck Accident Date: Date Format: MM slash DD slash YYYY 3. Truck Accident Details:4. Select: Truck Accident*Add another truck accidentDone4. Truck Accident Date: Date Format: MM slash DD slash YYYY 4. Truck Accident Details:5. Select: Truck Accident*Add another truck accidentDone5. Truck Accident Date: Date Format: MM slash DD slash YYYY 5. Truck Accident Details:Truck Accident With Injury Date Date Format: MM slash DD slash YYYY Truck Accident With Injury Details:Select: Truck Accident With Injury DetailsAdd another truck accident With Injury DetailsDoneTruck Accident With Injury Date Date Format: MM slash DD slash YYYY Truck Accident With Injury Details:3. Select: Truck Accident With Injury DetailsAdd another truck accident With Injury DetailsDone3. Truck Accident With Injury Date Date Format: MM slash DD slash YYYY 3. Truck Accident With Injury Details:4. Select: Truck Accident With Injury DetailsAdd another truck accident With Injury DetailsDone4. Truck Accident With Injury Date Date Format: MM slash DD slash YYYY 4. Truck Accident With Injury Details:5. Select: Truck Accident With Injury DetailsAdd another truck accident With Injury DetailsDone5. Truck Accident With Injury Date Date Format: 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* Date Format: MM slash DD slash YYYY PALMYRA TRAINING CALENDAR SAFETY STAFF ADMIN PAGE Need help? Contact Dirrick Simmons by email or phone: (434) 510-4000.
