Monthly Safety Report - Environment, Health & Safety

Page 1 of 2 The University of Michigan Monthly Safety Report (Submit by the 7th of next month) Project Name: UM Project Number: Construction Start Date: Construction End Date: Data for Month of: Date Submitted: Check here if in the construction phase but not yet mobilized or if substantially complete with no activity on site. Data is not required; Project manager may submit on behalf of contractor. INCIDENT TYPES Number of Cases U-M ProjectGoalRates Current Month Year to Date Project to Date National Average Year to Date Total Project OSHA Recordable Incidents 0 DART Incidents 0 Lost Work Incidents 0 Non-recordables, near misses, etc.

Data is not required; Project Manager may submit on behalf of contractor. INCIDENT TYPES Number of Cases U-M Project Goal Rates Current Month Year to Date Project to Date National Average Year to Date Total Project . OSHA Recordable Incidents 0 DART Incidents 0 Lost Work Incidents 0 . Non-recordables, near misses, etc. 0. 20BLS Construction Data

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1 Page 1 of 2 The University of Michigan Monthly Safety Report (Submit by the 7th of next month) Project Name: UM Project Number: Construction Start Date: Construction End Date: Data for Month of: Date Submitted: Check here if in the construction phase but not yet mobilized or if substantially complete with no activity on site. Data is not required; Project manager may submit on behalf of contractor. INCIDENT TYPES Number of Cases U-M ProjectGoalRates Current Month Year to Date Project to Date National Average Year to Date Total Project OSHA Recordable Incidents 0 DART Incidents 0 Lost Work Incidents 0 Non-recordables, near misses, etc.

2 0 2020 BLS Construction DataOSHA RECORDABLE INCIDENTS: Please classify Incident type below and also complete page 2 with details: Current Month Year to Date Project to Date Fall ( , floors, platforms, roofs) Struck by/against( , falling objects, vehicles) Caught in/between ( , cave-ins, unguarded machinery, equipment) Electrical ( , overhead power lines, power tools/cords, outlets, wiring) Overexertion Inhalation Heat Other (other items not covered above) EMPLOYMENT INFORMATION (includes contract workers) Average Daily Number of Employees (FTE s) Total Hours Worked by Employees PROJECT Safety ACTIVITIES Safety Orientations Completed Safety Huddles/Tool Box/Similar Activities Completed Documented Safety Inspections/Observations Completed Disciplinary Actions Medical, Fire and Other Emergencies MIOSHA Visits Safety Recognition Events (lunches/giveaways) Safety Recognition Program Awardees (list names on Page 2) MIOSHA CITATIONS Total number (serious, repeat or willful)

3 _____ Reviewed by U-M Project manager Date _____ Contractor Firm Name _____ Contractor Representative Date Safety Report - Revised 11/24/2021 The University of Michigan Monthly Safety Report (Submit by the 7th of next month) Page 2 of 2 DETAILS OF RECORDABLE INJURIES OR ILLNESSES: For all injuries and illnesses listed on page 1, include the date of the injury/illness and a paragraph with details describing the injury/illness, including if the injury/illness resulted in Lost Time or Restricted Work Activity/Transfer. Current Month: To Date: Safety FIRST CONTRACTOR Safety RECOGNITION PROGRAM AWARDEES: List names of employees recognized under GC/Trade Contractor s Safety Recognition Program Name of Awardee Subcontractor/Trade Contractor Date (MM/YYYY) Safety Report - Revised 11/24/2021

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