Great Lakes Lamination Incident Report (Injuries)

• Name of employee preparing incident report:

• What shift did incident occur on?

  First

  Second

• What Plant did incident occur at?

  Plant 1

  Plant 2

  Plant 3

  Plant 4/5

  Outside

Incident:

• Type of Report

  Select First Aid Near Miss Medical Treatment Recordable Incident Reasonable Suspicion Other

  • First Aid
  • Near Miss
  • Medical Treatment
  • Recordable Incident
  • Reasonable Suspicion
  • Other

Incident Details:

• Date and time of injury:

  Date

• General Location of Incident:

  Select Plant 1 Plant 2 Plant 3 Plant 4 Plant 5 Pallet Plant Maintenance Shop Rail Spur Outside Great Lakes Lamination N/A

  • Plant 1
  • Plant 2
  • Plant 3
  • Plant 4
  • Plant 5
  • Pallet Plant
  • Maintenance Shop
  • Rail Spur
  • Outside
  • Great Lakes Lamination
  • N/A

• Employee Name:

• Temp Employee?

• Employee's Supervisor:

• Location of Incident: (Be Specific)

• Picture of Location/Machine:

  Media

Supervisor Narrative:

• Detailed description of incident

• Reasonable Suspicion: Does the employee demonstrate any physical, behavioral, speech or performance indicators that lead to reasonable suspicion of drug or alcohol use? (if yes list indicators) <br><br>

  No

  Yes

• Safety Manager Informed?

  Yes

  No

• HR Manager Informed?

  Yes

  No

• Job Title:

  Select Tier 1 Tier 2 Tier 3 Builder Bander Set-Up Technician Forklift Driver Truck Driver Maintenance Technician Team Leader Manager N/A

  • Tier 1
  • Tier 2
  • Tier 3
  • Builder
  • Bander
  • Set-Up Technician
  • Forklift Driver
  • Truck Driver
  • Maintenance Technician
  • Team Leader
  • Manager
  • N/A

• Possible Cause or Causes of the incident: (Inadequate PPE, not paying attention to surroundings, failure to utilize safety equipment, etc.)

Employee statement:

• undefined

Witness statements

• Witnesses Name:

• Statement:

Injury Details if Applicable

• What treatment was performed? (Ice Pack, Band-Aid, splinter removal, etc.)

  Select Band-Aid Ice Pack Splinter Removal OTC Pain Reliever Ointment Wrap/Brace N/A Eye Flush

  • Band-Aid
  • Ice Pack
  • Splinter Removal
  • OTC Pain Reliever
  • Ointment
  • Wrap/Brace
  • N/A
  • Eye Flush

• Specific part of Body injured:

  Select

• Pictures of Injuries:

  Media

• Anyone else injured?

  Yes

  No

Corrective Actions: Short Term

• What was the immediate action taken to correct the issue (how was this done)?

• Who was the responsible party for correcting the issue?

Action: Long Term

• What is the long-term action needed to correct the issue?

• Who is the responsible party for correcting the issue?

HR Manager Conclusions:

• undefined