Arcadis Vietnam

PM/OHS/016

Monthly Project Injury Report

Project: Month: Year:

Total Hours Worked Lost Time Medical Aid First Aid Frequency

Year to Year to Year to

Month Year to Date Month Month Month Month Year to Date
Date Date Date

Injuries This Month

Injured Description of Date of Lost Time due Date of

Foreman Medical Aid First Aid
Employee Injury Injury to Injury Returned

Frequency Formula:

Frequency = Lost Time in Injuries x 200,000

Total Manhours Keyed for Period

Prepared by:
Date: