Josh Halpin

Ergo Issue Report

Use this to report any ergo complaints or incidents that may occur.

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Use this Template

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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.

Use this Template

Print as PDF

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.