Information
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Start Date:
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End Date:
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Reported By:
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Add Injury
Injury:
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Employees Name:
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Date of injury:
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What division
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Plant number
- Plant 19
- Plant 30
- Plant 26
- 19 Powder
- 30 Powder
- Plant 58
- Plant 66
- Plant 59
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Line number
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Injury Type:
- Flash burn
- Wire poke
- Laceration
- Contusion
- Abrasion
- Sprain/Strain
- Burn
- Debis
- Sliver
- Heat Cramps/Exhaustion
- Cold Weather Injury
- Puncture
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Body part injured:
- Head/Face
- Hand/Wrist/Finger
- Arm
- Knee
- Foot
- Leg
- Back
- Eye
- Abdominal
- Neck
- Mouth
- Shoulder
- Fingernail
- Toenail
- Ear
- Nose
- Ankle
- Toe
- Wrist
- Finger
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Additional Description:
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Treatment plan:
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In one or two sentences, How did the injury occur and what can be done to prevent it from happening again?
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Picture of injury ( tap to take photo)
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Option: Draw or sketch (the 5W's)
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Is This The Employees Error Injury/Accident?
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This is your disciplinary report warning for being negligent and careless. Your injury/injuries were preventable by following the guidelines established and implemented by the company for your protection. It is your responsibility to follow all protocols and/or policies and to wear the proper Personal Protective Equipment required by company policy. Further negligence may and can result in further disciplinary action; written, suspension, and/ or termination from the company.
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Supporting Photos:
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Additional Comments:
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Employees Signature:
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Management Signature:
