Information
-
Document No.
-
Client / Site
- Bonne Terre
- Kansas City Terminal
- MLDS Port Allen
- MLDS Ste. Gen
- MLDS Verona
- MLDS Vicksburg
- MLDS Weirton
- PDR
- Calera
- Chester
- Mobile
- Verona
- Vicksburg
- Weirton
- Mine
- MROT
- Office/Other
- PROT
- Road & Rail
- SMI/PCC
- Specialty
- Supply Chain
-
Date and Time Reported
-
Prepared by
Incident Information
Incident Information
-
Injured Employee Name
-
Job Title
-
Shift Type
-
Date and time employee began work
-
Date and time of incident
-
Date and time incident was reported.
-
Did incident occur on Mississippi Lime property?
-
Location of incident. (Specify site location)
-
Was there any witness(es)? If yes, provide name(s).
-
Witness Statement
DETAILS OF INJURY, IF APPLICABLE
-
Incident Description
-
What was the injury or illness
-
What body part was injured?
- Head
- R Ear
- L Ear
- R Eye
- L Eye
- Face
- Neck
- Back
- Abdomen
- Pelvic region
- L Shoulder
- R Shoulder
- L Upper Arm
- R Upper Arm
- L Elbow
- R Elbow
- L Forearm
- R Forearm
- L Wrist
- R Wrist
- L Hand
- R Hand
- L Thigh
- R Thigh
- L Knee
- R Knee
- L Lower Leg
- R Lower Leg
- L Ankle
- R Ankle
- L Foot
- R Foot
- Other
-
Cause of Injury
-
Type
-
Type
-
Type
-
Type
-
Type
-
Immediate corrective action
PROPERTY DAMAGE
-
Did property damage occur on the same incident?
-
Property Category
- Real Property (Buildings, Storage Units, etc...)
- Equipment (Machines, Computers, Instruments)
- Product (Raw Material, Finished Product, Packaging)
-
Property Damage Severity
-
Damage Description
-
Photo of Damage
-
Property ID: (If Applicable)
ENVIRONMENTAL IMPACT
-
Did this incident have an environmental impact?
-
Chemicals/Material Involved
-
Estimated quantity released (lbs, Gallons)
-
Duration of release (minutes)
-
Reportable quantity released?
-
Appropriate agency contacted?
-
If yes, list agency and point of contact
-
Released to:
-
How was the incident contained, controlled or corrected?
-
Clean up supplies used?
-
Clean up supplies replaced
LEARNING TEAM INFORMATION
-
Contributing (underlying) Factors:
-
Contributing factors photo:
-
Corrective Action (Include detail description of action and person(s) responsible for actions)
-
What was the potential for severity?
-
What could have potentially happened?
-
What is the probability of reoccurrance?
-
Select date
-
Signature
