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WHILE PERFORMING MAINTENANCE ON A JACKLEG DRILL, THE DRILL FELL AND CUT EE ON HIS RIGHT HAND BETWEEN THUMB AND INDEX FINGER.

AIR HOSE FROM DRILL CAME LOOSE HITTING EMPLOYEE IN RIGHT EYE.

THIS FORM IS BEING SUBMITTED SOLEY TO ABATE A CITATION. WE HAD NEITHER NOTIFICATION OR KNOWLEDGE OF THE CIRCUMSTANCES LEADING TO EE'S INJURY. THEREFORE WE ADMIT NO LIABILITY OR VIOLATION AT THIS TIME.

EMPLOYEE WAS SCALING TOP AT THE BOTTOM OF THE SLOPE. A PIECE OF SHALE FELL IN FRONT OF A PIECE OF EQUIPMENT. WHEN SHALE FELL, EE MOVED BACK AND SPRAINED HIS ANKLE. EE WAS NOT HIT BY PIECE OF S HALE.

EMPLOYEE WAS INSTALLING STEEL SETS AND SPRAINED HIS BACK.

WHILE ROOF BOLTING, A ROCK FELL FROM TOP STRIKING EE ON RIGHT CHEEK.

EE WAS CLIMBING OFF OF SHAFT JUMBO. HE FELL AND LANDED ON THE GROUND.

EE WAS PULLING THE SCREED TO THE BOTTOM OF THE CONCRETE POUR AND WAS LACERATED IN THE FINGER BYA BURR ON THE TUGGER CABLE.

WHILE MARKING THE FACE OF THE SLOPE, THE MUCKER RAN OUT OF FUEL AND STALLED. THE MUCKER ROLLED &HIT THE FACE, THROWING EE AGAINST THE FACE.

WHILE MARKING THE FACE OF THE SLOPE, THE MUCKER RAN OUT OF FUEL AND STALLED. THE MUCKER ROLLED &HIT FACE, THROWING EE OUT OF BUCKET.

WHILE MARKING THE FACE OF THE SLOPE, THE MUCKER RAN OUT OF FUEL AND STALLED. THE MUCKER ROLLED &HIT THE FACE, THROWING EE AGAINST THE FACE.

WHILE INSTALLING STEEL LAGGING, THERE WAS AN UNOPENED BUNDLE OF LAGGING ON THE BASKET. WHEN THE BUCKET WAS SET DOWN, THE BUNDLE SLID FORWARD LACERATING EMPLOYEE'S RIGHT FOOT.

EE'S RIGHT INDEX FINGER WAS CAUGHT BETWEEN THE END OF A DOUBLE JACK HANDLE AND A GUARD RAIL.

EMPLOYEE WAS CUTTING THE LEAD LINE WITH A CARPENTER'S KNIFE. THE KNIFE SLIPPED AND CUT HIS RIGHT INDEX FINGER.

FINGER WAS CAUGHT IN LATCH OF DUMP TRUCK TOOK 6 STITCHES.

WAS SETTING FROZEN PIPE IN PLACE WHEN ICE BROKE FREE & HIT HIM IN THE LEFT LEG.

EE WAS BLOWING OUT A 2" BULL HOSE. A LARGE PIECE OF ICE CAME OUT OF THE HOSE AND BROKE INTO SMALLER PIECES. ONE SMALLER ICE PIECE HIT EE ON LEFT CHEEK.

EE WAS ASSISTING IN UNLOADING A TRUCK OF REBAR HE BRUSHED AGAINST THE END OF A PIECE OF REBAR CUTTING HIS LEFT FOREARM

TWO EMPLOYEES WERE EACH HOLDING OPPOSITE ENDS OF A REBAR MAT. THEY WENT TO SHAKE THE REBAR MAT AND THE INJURED EMPLOYEE LOST HIS GRIP ON THE MAT HITTING HIM IN THE FACE UNDER THE RIGHT EYE.

EMPLOYEE WAS WALKING HIS DRILL FROM HOLE TO HOLE AND PASSED THE LOWER END OF THE DRILL SLIDE OVER HIS FOOT, AT THE SAME TIME THE OPPOSITE DRILLER JACKED HIS DRILL DOWN, CAUSING THE SLIDE TO CO ME DOWN ON THE RIGHT FOOT OF THE INJURED EMPLOYEE.

EE WAS ROOF BOLTING & A ROCK THE SIZE OF YOUR FIST CAME OUT OF ROOF & HIT EE IN THE NOSE

EE WAS ASSISTING TOPLANDER TAKING QUICK BEAMS OUT OF BUCKET, QUICK BEAM WAS NOT TIGHTENED DOWN, IT SLID CATCHING HIS HAND.

THE CREW WAS LOWERING THE 913 LOADER AND THE EE WAS ON THE WORK DECK AND SMASHED HIS INDEX AND MIDDLE FINGER ON HIS RIGHT HAND BETWEN THE WORK DECK AND THE WALL. Y

EE SLIPPED ON LOOSE MATERIALS WHILE GETTING INTO THE MUCK BUCKET. HE FELL AND JAMMED HIS LITTLE FINGER ON HIS LEFT HAND.

WHILE THE EE WAS CLEANING ROCK AND WOOD FROM UNDERNEATH THE CURBING, A ROCK FELL AND HIT CURB RING PUSHING THE CURB INTO HIS HEAD. (EE WAS WEARING A HARD HAT AT THE TIME.)

EMPLOYEE WAS SCALING LOOSE ROCK OFF THE SHAFT WALL WITH A 630 MUCKER. HE LOST CONTROL OF THE DIPPER AND A ROCK FELL STRIKING HIM IN THE LEFT RIB AREA.

ANOTHER EE WAS DRILLING HOLES FOR SPLIT SETS FOR PANNING SUPPORT. THIS EE WAS TRYING TO HELP DRILLER, HIS LEG SLIPPED CATCHING HIS HAND.

THE EE WAS POURING CONCRETE AND PUT HIS FOOT ON THE HANDLE OF THE CONCRETE BUCKET & THEN REMOVED HIS FOOT FROM THE HANDLE AND THE HANDLE HIT HISS RIGHT EAR.

EE WAS INSTALLING PANNING WITH SCREW GUN UNDER FAN LINE. THE HIGH VELOCITY AIR BLEW SHAVINGS ALL AROUND. EE WAS WEARING SAFETY GLASSES.

EE WAS STRIPPING BULKHEADS, WHEN THE BOARD HE WAS REACHING FOR LET GO AND A NAIL WENT INTO HIS THUMB.

BLOWING THE BOTTOM OF SHAFT PRIOR TO DEEPENING THE SHAFT AND A ROCK CAME OFF THE RIB

EE WAS RIGGING FORM JACKS AND TRIPPED AND FELL OVER POUR CHUTE AND HIT HIS TAIL BONE. POUR CHUTE WAS SITTING ON THE FLOOR OF THE WORKDECK.

2" BALL VALVE CAME APART RELEASING A 2" AIR HOSE THAT HIT HIM ON THE RIGHT THIGH.

EMPLOYEE WAS LOADING A DRINKING WATER JUG INTO A MUCK BUCKET AND STEPPED BACKWARD ONTO A RAIL AND TWISTED HIS ANKLE.

EE FELL WHILE CLIMBING DRILL JUMBO. FELL ON LEFT LEG AND TOE. EE DID NOT USE SAFETY EQUIPMENT IN PLACE AND PROVIDED.

EE WAS MOVING RIGHT SIDE FORK ON FORKLIFT, HAD LEFT HAND BEHIND FORK & SLIPPED OR LET GOT OF FORK WITH RIGHT HAND, FORK PINCHED LEFT HAND. EE DROVE HIMSELF TO CLINIC.

EE CAUGHT HIS FOOT IN WINCH AND HIS RT GREAT TOE WAS PULLED AS THE WORK DECK WINCH WAS CABLING UP.

THE CREW WAS MOVING THE SHAFT FORMS AND EE NOTICED SOMETHING ON THE WALL THAT DISTRACTED HIS ATTENTION AS HE WAS WALKING ON THE WORKDECK. EE THEN STEPPED THROUGH THE DOOR TO THE LOWER DECK WHI ICH WAS OPEN AT THE TIME.

WHILE HANDLING PANNING IT SLIPPED DOWN WITH CORNER CATCHING HIS LEFT LEG ABOVE KNEE.

EE WAS REMOVING ANGLE CHIPS FROM COLLAR STEEL AT THE ONTAKE SHAFT WITH A CUTTING TORCH WHEN SOME HOT SLAG POPPED INTO HIS LEFT EAR.

STEPS ON HOIST HOUSE BY THE HOIST GRIDS GAVE WAYAND THE EE LOST HIS STEP

A SECTION OF SUSPENDED REBAR-TPYE CONCRETE-REINFORCEMENT FELL AND STRUCK EMPLOYEE.

EE WAS PREPPING WELD ON PUMP TO PUT IN THE INTAKE SHAFT WHEN HE CUT HIS SMALL FINGER ON HIS LEFT HAND.

WHILE POURING CONCRETE EE WAS PULLING ON CONCRETE HOSE AND STRAINED BACK.

EE WAS WALKING AT WORKSITE AND SLIPPED ON SLICK ICY SURFACE.