Title Page
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Job Name and Number
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Conducted on
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Prepared by
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Location
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Name of Injured Teammate:
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Date of Birth:
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Date and Time of Incident
Incident Details
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What were you doing before the injury?
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Type of Injury:
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Body Part: (Arm, Hand, etc)
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Side of body?
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What were you doing?
- Tying
- Carrying
- Climbing
- Walking
- Prying
- Other
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Describe:
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Travel Distance?
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Weight?
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Describe Terrain Conditions? (Muddy, level, un-level, etc.)
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Was teammate using PPE?
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Type of equipment used (Hickey bar, Chokers, etc.)
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Was any hazardous material involved?
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What was the material involved?
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How did the injury happen?
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Was the hazard covered during Pre-task review?
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What specific unsafe act or condition was responsible for this accident?
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Why was this specific act or condition responsible for this accident?
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How long has employee been performing this task?
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How often is this tasked performed? (daily, monthly)
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How could this injury been prevented?
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Number of teammates involed?
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Was injury caused by another person
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Name of person that caused the injury?
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Were there witnesses?
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Has the witness completed the "witness accident report" form?
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Is this injury an original injury or a reinjury of a preexisting condition?
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Was site first aid adiminstered?
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Name of Foreman
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Name of Superintendent
Off-Site Treatment
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Did you see a doctor?
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Doctor:
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Facility:
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Address:
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Telephone:
Employee Signature
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Sign