WEEKLY SITE STATISTICS RETURN

PROJECT/CONTRACT NAME:

PROJECT/CONTRACT MANAGER:

SITE AGENT:

FOREMAN/SUPERVISOR: WEEK ENDING:

MAIN
SUB-
CONTRACTOR HOURS WORKED HOURS WORKED
CONTRACTOR TOTAL
EMPLOYEES (INCLUDE (INCLUDE
EMPLOYEES - ON HOURS
PERMANENT/ OVERTIME) OVERTIME)
SITE
CASUAL - ON SITE

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

TOTAL
INJURY STATISTICS
PRINCIPAL COM-
PERIOD CONTRACTOR PERIOD
CONTRACTOR MENTS

FATALITIES

LOST TIME INCIDENT

MEDICAL ONLY

FIRST AID

DETAILS OF THE INCIDENT (NAME OF CONTRACTOR):

SIGNED BY PROJECT/CONTRACTS MANAGER DATE

CK 0513

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