Pod Form 265 E – Fill Out and Use This PDF

Pod Form 265 E is made of a sturdy plastic material that can withstand up to 500 pounds. This product is best for people who are looking for something inexpensive and easy to assemble.

The right place to edit and work with this form is here. Our straightforward PDF editor will allow you to have your document in no time. Any platform you pick, whether a PC, laptop, smartphone, or tablet, can be used.

Get Form Now Download PDF

Pod Form 265 E first page preview

Pod Form 265 E PDF Details

Pod Form 265 E from tone the perfect option for businesses who need to print professional, high-quality documents without spending a fortune. This printer is easy to use and produces sharp prints with accurate colors every time. Plus, it's versatile enough to handle a wide range of projects, making it the ideal choice for any business.

Below is the details regarding the PDF you were looking for to fill in. It will show you the amount of time you will need to complete pod form 265 e, exactly what parts you will have to fill in, and so on.

Question	Answer
Form Name	Pod Form 265 E
Form Length	2 pages
Fillable?	Yes
Fillable fields	1
Avg. time to fill out	42 sec
Other names	form payable on death, payable on death template, pod form printable, bank payable on death form

12

Form Preview Example

Save As

Print Form

E-mail

U.S. ARMY CORPS OF ENGINEERS, PACIFIC OCEAN DIVISION HEADQUARTERS

IMMEDIATE REPORT OF ACCIDENT

For use of this form, see EM 385-1-1, the proponent agency is CEPOD-SO

SOHO USE ONLY

DATE RECORDED

TIME RECORDED

TO (COE OFFICE):

FROM:

1. NAME OF PERSON REPORTING ACCIDENT

1a. PHONE NO.

2. ACCIDENT INFORMATION (CHECK ALL THAT APPLY):

INJURY

INITIAL REPORT

CONTRACTOR

PROPERTY DAMAGE

ILLNESS

FOLLOW UP REPORT*

GOVERNMENT

OTHER (explain)

FATALITY

FINAL REPORT

PUBLIC

*A follow up report is due within 24 hours of any changes or additional information related to the accident (e.g., workers duty status)

3. CONTRACTOR/SUBCONTRACTOR	3a. CONTRACT NO.

4. LOCATION OF ACCIDENT (be specific, include project name and number)	4a. DATE OF ACCIDENT	4b. TIME OF ACCIDENT

5. NAME OF PERSON INVOLVED/INJURED (Last name, First name)

5a. AGE

5b. OCCUPATION

6.What was the activity before the accident occurred? Describe the activity, as well as the tools, equipment, or materials the employee was using (e.g., excavating with a backhoe, electrical equipment installation, demolition of facility, erecting structural steel):

7.What Happened? Tell how the injury, illness, or property damage occurred (e.g., struck by, contacted by, cut by, strained by, fell from same or different level, stung by):

8.What was the injury, illness or property damage (e.g., contusion, bruise, muscle strain, fracture, respiratory, allergic reaction, skin disease, poisoning, collapsed crane boom, engine fire, damaged utilities)?

9.Is the injury, illness, or property damage recordable as defined in OSHA 29 CFR Part 1904 or ER 385-1-99? If yes, an ENG Form 3394 must be submitted within 10 days. Note: An injury or illness is recordable if it results in death, days away from work, transfer to another job, restricted work, medical treatment

beyond first aid, loss of consciousness or other significant illness. Property damage of $2000.00 or more is recordable.

Yes

No

10.What medical treatment was required for the injury or illness (e.g., first aid, sutures, prescription medication, x-rays, cast)?

11.If medical treatment was given away from the work site, where was it given?

12.	Was employee hospitalized overnight as an in-patient?		13. Estimated days away from	13a. Estimated Job Transfer or	13b. Estimated days
	Yes	No	work:	Restricted Days:	hospitalized:


15.	Did accident result in property damage?		16. If yes, estimated property damage (if property damage is $2000 or greater ENG Form 3394
	Yes	No	must be completed and submitted)


17.	**Accident Board of Investigation Required?		17a. If yes, was immediate notification to the designated authorities made? District Safety Officer
	Yes	No
			and Commander must be notified of all serious cases.		Yes	No

**A board of investigation is required if the the accident results in: A. a fatality, B. three or more people admitted to the hospital, C. permanent total or partial disability, or D. property damage of $500,000 and greater.

18. NAME AND TITLE OF INDIVIDUAL WHO WILL INVESTIGATE THIS ACCIDENT

NAME AND TITLE OF PERSON REPORTING

PHONE:

SIGNATURE

DATE

POD FORM 265-E, OCT 2011

THIS FORM REPLACES POD 265-R DATED 14 JUN 2006.

Page 1 of 2

Save As

Print Form

E-mail

CONTINUATION PAGE

POD FORM 265-E, OCT 2011

Page 2 of 2

How to Edit Pod Form 265 E Online for Free

The PDF editor that you're going to begin using was developed by our main computer programmers. One could get the how to fill pod form form immediately and without problems using this application. Just keep up with this particular guideline to start out.

Step 1: Select the button "Get Form Here".

Step 2: So you are going to be on the file edit page. It's possible to add, adjust, highlight, check, cross, insert or delete fields or phrases.

Make sure you provide the following information to fill out the how to fill pod form PDF:

payable on death beneficiary form empty spaces to consider

Fill in the a, A, GEb, OCCUPATION and Yes section with the details asked by the application.

aAGEbOCCUPATION, and Yes in payable on death beneficiary form

Record any particulars you need within the field Yes, Yes, Estimated, days, away, from, work b, Estimated, days, hospitalized Did, accident, result, in, property, damage Yes, Yes, Yes, NAME, AND, TITLE, OF, PERSON, REPORTING PHONE, SIGNATURE, and DATE.

step 3 to finishing payable on death beneficiary form

When it comes to paragraph CONTINUATION, PAGE identify the rights and obligations.

payable on death beneficiary form CONTINUATIONPAGE fields to fill

Step 3: Choose the "Done" button. You can now transfer your PDF document to your electronic device. As well as that, you may forward it by means of email.

Step 4: To prevent possible upcoming troubles, ensure that you have up to several copies of every single file.

Watch Pod Form 265 E Video Instruction

Pod Form 265 E isn’t the one you’re looking for?

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .