(To print forms highlight each form and print as a selection at 93%)
City of Conover, North Carolina
Supervisor's Report of Accident / Injury
Please review Employee's account of incident and verify all information provided.
1. If any information is incorrect, please list item number(s) and the correct information below:___________________________________________________________________________
2. Was the incident caused by the employee's failure to use safety equipment or practices? If yes explain:____________________________________________________________________
4. Does supervisor or employee have any recommendations to correct conditions or prevent situation from reoccurring?___________________________________________________________________
7. Has the city's Insurance Officer (Gwen Lafone) been notified of the accident? _________________
8. Will the employee's ability to work be affected by the accident?_______________
In what way?______________________________________________________________________
9. Will the department's operations be affected by the accident?________________________________
In what way?______________________________________________________________________
Complete this section if Injury occurred:
10. Will the employee be limited or unable to work due to the injury?________
If yes, possibly how long?____________________________________________________________
This form must be completed and submitted to the Personnel Office within 24 hours of accident/injury. Copies will be forwarded to the Departmaent Head and the Safety Director.
(Revised 6/97)
City of Conover, North Carolina
Employee's Report of Accident / Injury
1. Check one: Accident only________ Injury only__________Accident with injury____________
13. Married _____________ Single___________ Home Phone_________________________
Widowed ___________ Divorced_______ Number of Dependants under 18 _____________
14. Part of body injured________________________________________________________
15. Type of injury____________________________________________________________
16. Describe how injury occurred_________________________________________________
Headworks
Close air valve and observe the rake and conveyor (If the rake does not run check to
see if the motor is turning, if it is turning and the rake isn't moving it
probably sheared a pin, if the motor is not turning, check breaker(If unsure call Michael)
Check the grit drag ramp and if the metal is covered with a light coating of brown rust. If so contact Michael
Observe the blower (belts and noise) Lift Station
Make sure the water in the lift station is below the flume Check Pond for dead fish or clogged overflow Digesters
Make sure the digester blower is running (unless otherwise
notified)
Observe any offensive odors Operations Lab Building
Sign ORC Log
Write down time, flow, and totalizer
Record sechi reading
Record decant time and reset clock
Change flow chart
Write down weather conditions
Write down Cl2 and Bisulfite volume
Observe aquarium for dead or sick fish (If fish are dead:
check aquarium Cl2 residual, if you have a high Cl2 in the aquarium,
Check Cl2 in clear well and effluent. If Cl2 is high in the clear
well it is probably
If the Cl2 is high in effluent and low in the clear well it is
probably a leak in the disinfect tank
Note the Cl2 volume in the disinfect tank and the chem clean tank
Observe if there is an unusual amount of solid on the bottom of
the aquarium Reactors
Observe basin depths
Observe odor and floc color Control Room
Check alarm lights
Record blower and waste sludge hour meeting readings Digester
Check WAS digester depth
If it is extremely high check to see if the SE Sludge transfer pump is off (it should be off) Sand Filter
Check compressor tank pressure
Check alarm lights
Write down backwashes Press backwash button on each filter
Heavy Rain Options
If the basins show very high volume during aeration or settling cycle you may
First check to see if the rain is supposed to continue
If rain is ending soon, cut back air (and or) trip storm flow
float
In extreme situations all reactor functions may be cut off
If reactor functions are cut off they must be attended and started back over a
long period of time
In heavy rains it may be necessary to bypass the sand filters due
to their
loss of
effectiveness (this is done by closing inlet valve)
During heavy flow situations their are many judgment calls to be
made Compliance Laboratory Record Cooler and Incubator Temperatures
