CONTRACTOR’S REPORT OF INJURY OR ILLNESS

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BPA F 6410.15e
(10-2023)
Page 1 of 3

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/xxxx

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.
BPA Safety Office Use Only: Case Number:
A. Information Regarding Injured or Ill Contractor
1. Job Title

2. Name of Contracting Company

3. Address of Contracting Company
4. BPA ORG Code Assigned to Contractor

5. Contract Number

6. Name of Project Involved
8. Date of Accident (MM/DD/YYYY)
10. Time Contractor Began Work (HH:MM)

7. Location of Injury or Illness
9. Time of Accident (HH:MM)
11. Was BPA property damaged?

Yes

12. 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 key-entry.”).

File Code: PE-53-17; Retention: Retain for 10 years and then dispose.

No

BPA F 6410.15e
(10-2023)
Page 2 of 3

CONTRACTOR’S REPORT OF INJURY OR ILLNESS

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

13a. 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.”)

13b. 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 (This PDF form will support 4
pictures maximum, if you need to submit more than 4 pictures then submit separately).

13c. 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.”).

File Code: PE-53-17; Retention: Retain for 10 years and then dispose.

BPA F 6410.15e
(10-2023)
Page 3 of 3

CONTRACTOR’S REPORT OF INJURY OR ILLNESS

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

14. 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.

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

16a. Contract Worker Employer’s Representative’s Signature
16b. Contract Worker Employer’s Representative’s Title
16c. Office Phone Number (Include area code)

16d. Date

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.

File Code: PE-53-17; Retention: Retain for 10 years and then dispose.