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Title Page
Who has the issue or complaint?
Enter date
Is this a complaint (operator brought up an issue about a specific part of a station or job job) or an incident (an event happened resulting in injury)?
Did the operator report this issue before?
Enter a brief but detailed description of issue or complaint.
Station Name
Team 1
Team 2
Team 3
Team 4
Team 5
Team 6
1 Bow
Garnish/Seal Prep
Hydraulic A
Hydraulic B
Hydraulic to Frame
Kinematic Prep
Rail Prep/Tension Bow
Repack
Rework
Top Cover
TSSA
Warehouse
Other
If other was selected please enter station/area below
Please select which body part(s) are causing the problem (Check all that apply)
Back
Neck
Left Shoulder
Right Shoulder
Left Elbow
Right Elbow
Left Wrist
Right Wrist
Who was the issue/complaint reported to?
Have you been rotated from this station previously?
Person who has issue or complaint please sign below.
Prison who is filling out report sign below
Josh Halpin
Ergo Issue Report
Use this to report any ergo complaints or incidents that may occur.
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions.
The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice.
You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction.
You should independently determine whether the template is suitable for your circumstances.
