New snippet 494

Incident Type

Incident Type *

Please select an incident type.

Employee Information

Employee Name *

Please select an employee name.

Hire Date

Organization Area

Department

Job Position

Incident Details

Location of Injury *

Please select location.

Location Equipment *

Please select an equipment.

Equipment Location

Equipment Serial No

Equipment Model No

Equipment Number

Department at time of Incident *

Please select position at time of the incident

Position at time of Incident *

Please select position at time of the incident

Task at time of Incident *

Please select task at time of the incident

Years of Experience *

Please select years of experience at time of the incident

Incident Reporting Details

Incident Date *

Please select a valid date.

Incident Time *

Reporting Date *

Please select a valid date.

Reporting Time

Reported To *

Please select supervisor name.

Return to Work

RTW Program Offerred?

No Yes

Modified Offer Letter Given?

No Yes

FAF Given

No Yes

Description of Incident

State exactly the sequence of events leading up to the incident (where, when, how, etc.):

Provide additional details such as: height of lifts, weight/size of object, distanced moved, frequency of movement/activity/reach/lift:

Pictures

Choose file

Please select a policy file. Must be pdf file format.

Choose file

Please select a policy file. Must be pdf file format.

Choose file

Please select a policy file. Must be pdf file format.

Witness

Were there any witness?

How many other people were involved?

1

2

None

1

2

3

4

5

None

Witness Statement #1

Witness Statement #2

Correctieve Actions

Elimination

Modify Equipment

Repair or Replace Equipment

Automate Process

Substitution

Modify Equipment

Repair or Replace Equipment

Engineering

Install Guard or Safety Device

Interim Device

Modify Process Design

Administrative

Create/Review Procedures

Follow Manufacturers Recommendations

Improve Housekeeping

Job Safety/Hazard Analysis

Modify Associates Rotation

Modify Inspection Process

ReAssign Associate/Work

Reinstruct Associate

Reinstruct Supervisors

Reinstruct Team

Review/Revise/Create PM

Signage

PPE

Improve PPE

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Name	Position	Office	Age	Start date	Salary
Name	Position	Office	Age	Start date	Salary

Incident Type

Employee Information

Incident Details

Incident Reporting Details

Incident Details

Area of Injury

Type of Event

Description of Incident

Pictures

Witness

Were there any witness?

How many other people were involved?

Immedaite Causes

Basic or Root Causes

Correctieve Actions

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