Monthly Statistical Data Report

This report is required by ALL contractors and subcontractors performing work on this
project.

Submit a separate report for each contract, each month, by the end of the first week of
the next month, regardless of whether or not an injury occurred.

Contractor/Company Name:

Purchase Order No:

Contract Representative:

Month Ending:

Current Month Total to Date

Fires

Government Inspections

Spills or Releases of Hazardous Materials

Near Miss Reports

Total First Aids for the Month

Total Medical Aids for the Month

Total Lost Workday Cases (LTAs) for the Month

Total Lost Workdays for the Month

Total Personnel Hours Worked for the Month

Submitted By: Date: