Electrical Source Holdings

HSF-003 Employee Report of Incident

Name: ANDRES REYES Name of Supervisor: ANDREW BOYD

Job Title: ROBOTICS TECHNICIAN Company: FACTORY SURPLUS DIRECT INC.

Incident was a:
Near Miss x Injury Property Damage Automobile Customer Incident

Location of Incident: 30 Minto Rd, Guelph / Linamar Performance Centre

Date of Incident: 05/16/23 Time of Incident: 4:25 a.m. x p.m. Time your workday began: 9:00 x a.m. p.m.

Date Reported: 05/17/23 Time Reported: 09:00 x a.m. p.m. Reported to Who:

What happened? Please explain in detail, continue on back of form if needed:

At the moment whet I was going up to check the customer robot (mezzanine), i did not realize that the gripper was
moved so, I hit my head with a sharp steel piece of the gripper. Causing a skin cut and bleeding.

What personal protective equipment is required for the job: Was proper safety equipment worn: x Yes No
x Safety Glasses / Goggles Face Shield x Hearing If no, explain why:
Protection x Gloves Respirator Apron
Other: ______________________________________________

What tools / equipment are provided to complete job safely? Were proper tools / equipment utilized: Yes No
If no, explain why:

Were you performing this job alone? x Yes No Witness(es): Customer Employ
Please list any unsafe conditions that contributed to the incident:

Unstable ladder

What could be done to prevent this incident/accident from happening again?

Be aware of the surroundings on workplace

Continue below for injury incidents - part of the body affected (indicate RIGHT or LEFT where applicable):
Head & Neck: Upper Extremities: Lower Extremities: Trunk:
x Head Shoulder R side / L side Upper Leg R side / L side Back R side / L side
Face x Upper Arm R side / L side Lower Leg R side / L side Upper
Ear R side / L side Elbow R side / L side Knee R side / L side Middle
Nose Forearm R side / L side Ankle R side / L side Lower
Mouth/Teeth Wrist R side / L side Foot R side / L side Chest R side / L side
Eye R side / L side Hand R side / L side Toe(s) ______________ Abdomen
Neck R side / L side Finger(s) ____________ Other _______________ Hips / Pelvis
Other __________________ Other _______________ Other _________________

I CERTIFY the above is true and correct to the best of my knowledge.

05/17/23
Signature of Employee Date Completed
--For Safety Use Only--
Incident # _________________________________ W/C Carrier Claim # ________________________________ Doc. No.: HSF-003
Date Report filed with W/C. Carrier ____________________ Rev.: 1
Revision Date: 03/25/22