RENCO ELECTRONICS, INC.

Transcription

1 Directions: Complete sections 1, 2, and 3 for all accidents and incidents. Accidents or incidents that require medical attention or lost or restricted work require the signature of Human Resources. Attach additional sheets as necessary. Send completed forms to Human Resources. SECTION I EMPLOYEE INFORMATION : Hire Date: SSN: : Job Title: ( ) Full Time ( ) Part Time ( ) Temp ( ) Student/Intern ( ) Other SECTION II ACCIDENT INFORMATION Date of Incident: Location: Time of Incident: Time Employee Began Work: AM/PM Type of Incident: ( ) Accident ( ) Injury (check all that apply) ( ) Illness ( ) Other What was the employee doing just before the incident occurred? Describe the activity as well as the tools, equipment, materials, or chemicals the employee was using just before the incident. What happened? Describe the incident.

2 What was the injury/illness? Describe what part of the body was affected and how it was affected. Part of Body Affected (check all that apply) ( ) Head ( ) Face ( ) Eyes ( ) Ears ( ) Neck ( ) Shoulders ( ) Chest ( ) Abdomen ( ) Groin ( ) Back Upper ( ) Back Lower ( ) Buttocks ( ) Fingers ( ) Hands ( ) Wrist ( ) Arms ( ) Toes ( ) Feet ( ) Lower Leg ( ) Knee ( ) Upper Leg ( ) Lungs ( ) Nervous System ( ) Blood System ( ) Skeletal System ( ) Digestive System ( ) Reproductive System ( ) Skin ( ) Other: How was it Affected? (check all that apply) ( ) Abrasion ( ) Amputation ( ) Bruise ( ) Burn (chemical) ( ) Burn (heat) ( ) Loss of Hearing ( ) Constant Pain ( ) Crushed ( ) Cut/Laceration ( ) Dermatitis ( ) Dismemberment ( ) Eye Injury ( ) Fracture ( ) Heart Attack ( ) Infection ( ) Loss of Feeling ( ) Industrial Illness Repeated Exposure ( ) Industrial Illness One-Time Exposure ( ) Inflammation ( ) Concussion ( ) Loss of Sight ( ) Poisoning ( ) Puncture ( ) Strain/Muscle Pull ( ) Sprain ( ) Stroke ( ) Swelling ( ) Trauma ( ) Unconsciousness ( ) Other:

3 What object or substance directly harmed the employee? Examples, concrete floor, chlorine, or grinding wheel fragments. If this question does not apply to the incident, leave it blank. Personal Protection Equipment Used: (check all that apply) ( ) Glasses ( ) Goggles ( ) Face Shield ( ) Gloves ( ) Respiratory Protection ( ) Foot Protection ( ) Head Protection ( ) Full-body Protection ( ) Fall Protection ( ) Apron/Chaps ( ) Back Belt ( ) Lifting Assistance Device ( ) None ( ) Other: SECTION III TREATMENT INFORMATION Did the employee receive medical treatment? ( ) YES (list below) If received, who provided it? ( ) Self ( ) Employee Health Services ( ) Urgent Care Facility : ( ) Emergency Room Facility : ( ) Other: ( ) Treated and Released ( ) Hospitalized (release date): ( ) check if date cannot be determined at this time Was this activity part of the employee s regular job? ( ) YES Did the employee lose any work time after the accident? ( ) YES If yes, the date(s) and time away from work began at AM/PM Date employee returned to work: ( ) check if date cannot be determined at this time Did the employee die as result of this accident? ( ) YES

4 SECTION IV ACCIDENT/INCIDENT INFORMATION Were there any witnesses or other employees directly involved? ( ) YES Root causes and contributing factors: (the attached checklist may be used as a guide if needed) Why did each of the above items exist? (link #1 with #1 root cause, etc.) Corrective Actions: (list what long term actions are being taken as a result of this incident)

5 I certify that the information above information is given to the best of my ability. Employee/Injured Party Signature Employee/Injured Party (print) Date Supervisor Signature Supervisor (print) Date Human Resources Signature Human Resources (print) Date