BPA F 6410.18e CONTRACTOR’S REPORT OF INCIDENT/NEAR-HIT

BPA F 6410.18e
(05-2022)

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

CONTRACTOR’S REPORT OF INCIDENT/NEAR-HIT

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

Safety Incidents are to be promptly reported by involved employees to their immediate supervisor. The supervisor and
employee will complete the Contractor’s Report of Incident / Near-Hit.
This report will be required for reporting incidents that DO NOT involve personal injury, illness, or property damage.
Accidents involving personal injury, illness, or property damage require filing BPA F 6410.15e (Contractor’s Report
of Personal Injury, Illness, or Property Damage).
This form will be submitted via email to the Inspector or Natural Resource Specialist for the project. The form will be
submitted to the Contracting Officer and the Safety Office within five (5) working days of such an occurrence.
Date:

Time:

Project Title:

1. Company Name

2. Location of Incident

3. Name(s) of employees involved (print clearly or type)

4. Explain exactly what happened

5. Explain why it happened

6. Action(s) taken to prevent future recurrence

7. Reported by (Name) (print clearly or type)
9. Reviewed by BPA Designated Employee:
a. Name (print clearly or type)

8.Signature

b. Title

c. Date Reviewed

If INJURY/ILLNESS: Retain while Active + 6 years, and then dispose. Active period ends upon termination of compensation or when deadline for filing a claim has
passed. (source: PE-53-11, Retention Schedule: GRS-1/31) If PROPERTY DAMAGE: Retain while Active + 3 years, and then dispose. Active period ends upon closure
of claim. (source: PE-53-15 & 16, Retention Schedule: GRS-18/15(a)) If FATALITY: Retain while Active + 75 years, and then dispose. Active period ends upon
closure of case. (source: PE-53-12, Retention Schedule: N1-305-07-1-14/d)

BPA F 6410.18e

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

CONTRACTOR’S REPORT OF INCIDENT/NEAR-HIT

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

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 non-injury incidents and near hits 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.