BPA F 6410.15e CONTRACTOR’S REPORT OF INJURY OR ILLNESS

BPA F 6410.15e
(XX-2023)

U.S. DEPARTMENT OF ENERGY-BONNEVILLE POWER ADMINISTRATION (BPA)

CONTRACTOR’S REPORT OF INJURY OR ILLNESS

OMB Control Number:1910-XXXX
Expiration Date: xx/xx/xxxxx

BPA Safety Office Use Only: Case Number:
Privacy Act Statement:
Authority: 5 U.S.C. 301 and the Department of Energy Organization Act.
Purpose: BPA will use this information to document and analyze incidents resulting in injury and develop appropriate corrective action.
Routine Uses: A record from this system may be disclosed to physicians who treat injured or ill federal employees or contractors and the Department of Labor to maintain a
record of occupational injuries or illnesses. A record in this system may be disclosed to the appropriate local, state, or federal agency when the records alone, or in conjunction
with other information, indicate a violation or potential violation of law, whether civil, criminal, or regulatory in nature. A record from this system may be disclosed for the purpose of
an investigation, settlement of claims, or the preparation and conduct of litigation. Additional routine uses of the information contained in this record are listed in DOE-38.
Disclosure: Lack of disclosure will not result in criminal penalties; however, failure to furnish this information may delay or preclude the pursuit of corrective action.

We value safety in everything we do. Together, our actions result in people being safe each day, every day. At work, at home and at play, we contribute
to a safe community for ourselves and others. Together and individually, we demonstrate our commitment to safety by:
•
Taking the time to do our work safely;

•

Taking actions to prevent and eliminate hazards;

•

Speaking up when we see an unsafe situation; and

•

Incorporating safety into everything we do, including how we define success.

Instructions: Complete and email to the Contracting Office Representative (COR). COR is responsible for reporting incident in OSHIS
including uploading a copy of this form.

A. Information Regarding Injured or Ill Contractor
1. Job Title

2. Name and Address of Contracting Company

3. BPA ORG Code that Contractor assigned to

4. Name of Project Involved

7. Date of Accident (Month, Day, Year)

8. Time of Accident (Specify AM/PM)

5. Contract Number

6. Location of Injury or Illness

9. Time Contractor Began Work (Specify AM/PM)
AM
PM
Minute:
Hour:

10. What was the Contractor doing just before the Injury or Illness occurred? Describe the activity, as well as the tools, equipment, or material the
Contractor was using. Be specific. (Examples: “climbing a ladder while carrying materials”, “spraying chlorine from a hand sprayer”, ‘daily computer keyentry.”)

11. What Happened? Explain how the injury or incident occurred. Examples: “When ladder slipped on wet floor, worker fell 20 feet”. “Worker was
sprayed with chlorine when gasket broke during replacement”, “Worker developed soreness in wrist over time.”

11a. Photo(s) WARNING: Do not show pictures of injuries just conditions surrounding the injury taking place. Contract company may submit
their own report but this form must be filled out and submitted to the BPA Safety office. (PDF will not support pictures) Submit separately.
12. What was the injury or illness? Explain the part of the body that was affected and how it was affected; be more specific than “hurt,” “pain,” or “sore.”
Examples: “strained back”, “chemical burn, hand”, “carpal tunnel syndrome.”

13. What object, circumstance, or substance directly harmed the Contractor? Examples: “Impact with object”, “chemical exposure”, “radial arm saw.” If
this question does not apply to the incident, leave blank or not applicable. Please attach any witness statements or reports.

14. Any lessons learned that may create a safer work environment?

15. BPA Foreman or Immediate Supervisor (Signature)

a. Title

b. Office Phone Number

e. Date

Retain for 10 years and then dispose. (Source: PE-53-17, Retention Schedule: N1-305-07-1-14/c)

BPA F 6410.15e
(XX-2023)

U.S. DEPARTMENT OF ENERGY-BONNEVILLE POWER ADMINISTRATION (BPA)

CONTRACTOR’S REPORT OF INJURY OR ILLNESS

OMB Control Number:1910-XXXX
Expiration Date: xx/xx/xxxxx

Paperwork Reduction Act Burden Disclosure Statement
This data is being collected to ensure the safety of BPA’s contract workers. The data you supply will be used by BPA
to document, track, and report contractor injuries to BPA on BPA contracts. Public reporting burden for this
collection of information is estimated to average .25 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining that data needed, and completing and
reviewing the collection of information
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to Office of the Chief Information Officer, Enterprise Policy Development &
Implementation Office, IM-22, Paperwork Reduction Project (OMB control number 1910-XXXX), U.S. Department
of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget
(OMB), OIRA, Paperwork Reduction Project (OMB control number 1910-XXXX), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject
to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork
Reduction Act unless that collection of information displays a currently valid OMB control number
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the
Office of Management and Budget (OMB) before undertaking a collection of information directed to 10 or more
persons of the general public, including persons involved in or supporting the operations of Government-owned,
contractor-operated facilities.
Submission of this data is required.