Information
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Audit Title
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Employee Name
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Supervisor's Name
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Phone of Supervisor
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Site
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Location
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Date of Incident
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Date of Report
Injury or Illness
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Part of Body
- Head
- Left Hand
- Right Hand
- Respiratory Track
- Left Eye
- Right Eye
- Left Ear
- Right Ear
- Left Leg
- Right Leg
- Left Arm
- Right Arm
- Trunk
- Back
- Digestive Track
- Toe
- Left Foot
- Right Foot
- Left Knee
- Right Knee
- Skin
- Face
- Neck
- Left Ankle
- Right Ankle
- Left Elbow
- Right Elbow
- Other
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Which Extremities
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Describe for Other
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Take Photo
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Days Lost
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Sex
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Nature of Injury or Illness
- Fracture
- Contusion
- Inflamed
- Lacerations
- Burn
- Dislocation
- Irritation
- Amputation
- Bruises
- Teeth Chipped
- Loss of Consciousness
- Strain
- Abrasion
- Chemical
- Sprain
- Puncture
- Convulsion
- Convulsion
- Missing Teeth
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Type of Contact
- Fracture
- Contusion
- Inflamed
- Lacerations
- Burn
- Dislocation
- Irritation
- Amputation
- Bruises
- Teeth Chipped
- Loss of Consciousness
- Strain
- Abrasion
- Chemical
- Sprain
- Puncture
- Convulsion
- Convulsion
- Missing Teeth
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Contact with
- Electricity
- Heat
- Cold
- Chemicals
- Radation
- Other
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Enter other details
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Experience - How long have they been working for IME
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Risk
Property Damage
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Property Damaged
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Nature of Damage
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Estimated Cost
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Actual Cost
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Object Inflicting Damage
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Person in Control
Other Actual or Potential Loss
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Type of Loss
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Cost (if applicable)
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Nature of Loss
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Material or Object related
Event Details
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Loss Severity Potential
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Probability
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Describe how the event occurred
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Sketch or Picture?
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Draw site
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Take Photo and annotate
Immediate Causes
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Substandard Actions
- Operating equipment without authority
- Failure to warn
- Failure to secure
- Improper lifting
- Operating at improper speed
- Making safety devices inoperable
- Removing safety devices
- Using defective equipment
- Using equipment improperly
- Failure to use personal protective equip
- Improper loading
- Improper position for task
- Servicing equipment in operation
- Substance abuse
- Horseplay
- Other
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Substandard Conditions
- Inadequate guards or barriers
- Inadequate or improper protective equipment
- Defective tools or equipment or materials
- Congestion or restricted action
- Inadequate warning system
- Fire and/or explosion hazard
- Poor housekeeping
- Hazardous environmental conditions (gas, smoke, etc)
- Noise exposure
- Radiation exposures
- Temperature exposures (high/low weather conditions)
- Inadequate or excessive illumination
- Inadequate ventilation
- Other
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Explanation
Basic Causes
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Personal Factors
- Inadequate capability = mental or physical capability, physical or physiological Stress
- Lack of knowledge = lack of experience, inadequate, orientation or initial training or updated training, misunderstood directions
- Lack of skill = inadequate initial instruction or practice or performance or lack of coaching
- Stress = physical or mental
- Improper motivation = improper performance is rewarding! proper performance is punishing! no incentives, improper attempt to: save time, avoid discomfort, or to gain attention, inadequate peer pressure, improper supervisory example, improper production incentives
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Job Factors
- Inadequate guards or barriers
- Inadequate or improper protective equipment
- Defective tools or equipment or materials
- Congestion or restricted action
- Inadequate warning system
- Fire and/or explosion hazard
- Poor housekeeping
- Hazardous environmental conditions (gas, smoke, etc)
- Noise exposure
- Radiation exposures
- Temperature exposures (high/low weather conditions)
- Inadequate or excessive illumination
- Inadequate ventilation
- Other
Remedial Actions
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Corrective Action
Resolution
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Corrective Action
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Explanation
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Abatement Date
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Completed
Treatment
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Treatment Given From
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Post Accident Substance Testing
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Explain reason for no substance test
Approvals and information
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Employee Name
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Employee ID #
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Employee Signature
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Supervisor Name
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Supervisor Signature
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Witnesses
Witness
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Witness Name
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Signature
