CONTRACTOR’S REPORT OF INCIDENT/NEAR-HIT/PROPERTY DAMAGE

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BPA F 6410.18e
(10-2023)
Page 1 of 2

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

CONTRACTOR’S REPORT OF INCIDENT/NEAR-HIT/PROPERTY DAMAGE

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

NOTE:
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/Property Damage.
This form will be submitted 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. Names of Employees Involved:

4. Explain exactly what happened:

5. Explain why it happened:

6. Action(s) taken to prevent future recurrence:

7a. Reported By (Name)
7b. Signature
8a. Reviewed by (BPA Designated Employee Name)
8b. Title

8c. 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: GRS18/15(a)). If FATALITY: Retain while Active + 75 years, and then dispose. Active period ends upon closure of case (Source: PE-5312, Retention Schedule: N1-305-07-1-14/d).

BPA F 6410.18e
(10-2023)
Page 2 of 2

CONTRACTOR’S REPORT OF INCIDENT/NEAR-HIT/PROPERTY DAMAGE

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.

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: GRS18/15(a)). If FATALITY: Retain while Active + 75 years, and then dispose. Active period ends upon closure of case (Source: PE-5312, Retention Schedule: N1-305-07-1-14/d).