Sabre Corporate Incident Investigation Report

• Report Time and Date

  Date

• Initial Report by

• Location of Incident

  Select Sioux City, IA Conroe, TX Alvarado, TX Kennedale, TX Hicksville, OH Bossier City, LA Oklahoma City, OK Champagne, IL Lee Summit, MO North Aurora, IL Leesburg, FL Lexington SC Lexington OH

  • Sioux City, IA
  • Conroe, TX
  • Alvarado, TX
  • Kennedale, TX
  • Hicksville, OH
  • Bossier City, LA
  • Oklahoma City, OK
  • Champagne, IL
  • Lee Summit, MO
  • North Aurora, IL
  • Leesburg, FL
  • Lexington SC
  • Lexington OH

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• Which Department at the site?

• Was EHS notified? (You have to check the box to move on) Kyle Black 712.560.5184 Jeremy Nelson 712.389.8767 Robert Schmeckpeper 712.389.1695

  Yes

• Was EHS notified? Kyle Black 712.560.5184 Jeremy Nelson 712.389.8767 Robert Schmeckpeper 712.389.1695

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• What department do you work for?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• Was EHS notified? Jon Martin 712.535.1643 Manuel Oville 832.766.1209

  Yes

• Was EHS notified? Jon Martin 712.535.1643

  Yes

• Was EHS notified? Jon Martin 712.535.1643

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• What department do you work for?

• Was EHS notified? Mick Mikel: 214.790.4404 Aaron Gonzalez: 817.829.4058 Chuck Nelson: 214.587.6513

  Yes

• Was EHS notified? Mick Mikel: 214.790.4404 Aaron Gonzalez: 817.829.4058 Chuck Nelson: 214.587.6513

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• What department do you work for?

• Was EHS notified? Christine Rodriquez: 682.321.4624 Gary Cartwright 817.233.7411

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• What department do you work for?

• Was EHS notified? Drew Wort 712.223.3468 Tim Wells 419.487.3115<br>

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• What department do you work in?

  Yes

• Was EHS notified? Bob Elliott 318.465.7880 Casey Honeycutt 318. 553.4138

  Yes

• Was EHS notified? Bob Elliott Casey Honeycutt

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• Who in Safety was notified?

  Select Kyle Black 712.560.5184 Jeremy Nelson 712.389.8767 Robert Schmeckpeper712.389.1695

  • Kyle Black 712.560.5184
  • Jeremy Nelson 712.389.8767
  • Robert Schmeckpeper712.389.1695

• Was EHS Notified? Katie Long – 217-474-4401 Shane Polly – 217-552-2456 Aaron Steeneck – 712-301-8245<br>

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• Was EHS notifed? Katie Long – 217-474-4401 Shane Polly – 217-552-2456 Aaron Steeneck – 712-301-8245<br>

  Yes

• Which division at site?

• Was EHS Notified? Katie Long – 217-474-4401 Shane Polly – 217-552-2456 Aaron Steeneck – 712-301-8245<br>

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• Was EHS Notified? Katie Long – 217-474-4401 Shane Polly – 217-552-2456 Aaron Steeneck – 712-301-8245

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• Was EHS Notified? Katie Long – 217-474-4401 Shane Polly – 217-552-2456 Aaron Steeneck – 712-301-8245<br>

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• Was EHS Notified? Katie Long – 217-474-4401 Shane Polly – 217-552-2456 Aaron Steeneck – 712-301-8245<br>

  Yes

• Which division at site?

  Select Sabre Telecom Products Sabre Tubular Structure Sabre Site Services Sabre Galvanizing Services Sabre Tower Services Sabre Corporate Sabre Building Solutions

  • Sabre Telecom Products
  • Sabre Tubular Structure
  • Sabre Site Services
  • Sabre Galvanizing Services
  • Sabre Tower Services
  • Sabre Corporate
  • Sabre Building Solutions

• Was EHS Notified? Katie Long – 217-474-4401 Shane Polly – 217-552-2456 Aaron Steeneck – 712-301-8245<br>

  Yes

Employee Section

• What Time did the Incident occur

  Date

• Name of Employee involved

• Employee Title

• Superviors Name

• Employee Phone Number

• Employee Address

• Incident Location: Building/ Bay or Line/ Workstation number / Work Site

• Incident Time

  Date

• Incident Type

  Select Property Damage Fire Caught Between Chemical Exposure Chemical Release Crush / Pinch Point Cut / Scrape / Laceration Electric Shock Exposure to Body Fluid or Infectious Material Slip Trip or Fall Frostbite Inflammation / Bruising Only Near Miss Strain or Sprain Struck by or against Traumatic Injury (Fx/ Dislocation) Workplace Violence

  • Property Damage
  • Fire
  • Caught Between
  • Chemical Exposure
  • Chemical Release
  • Crush / Pinch Point
  • Cut / Scrape / Laceration
  • Electric Shock
  • Exposure to Body Fluid or Infectious Material
  • Slip Trip or Fall
  • Frostbite
  • Inflammation / Bruising Only
  • Near Miss
  • Strain or Sprain
  • Struck by or against
  • Traumatic Injury (Fx/ Dislocation)
  • Workplace Violence

• What was damaged?

  Select Crane/Cart Production Machine Hydraulic Pump Nissan or small forlift Taylor or large forklift Selick or medium foorklift Combi or side drive forklift Welder Ladder Power Tool Hand tool Shuttle Lift Company Vechicle Torch Other

  • Crane/Cart
  • Production Machine
  • Hydraulic Pump
  • Nissan or small forlift
  • Taylor or large forklift
  • Selick or medium foorklift
  • Combi or side drive forklift
  • Welder
  • Ladder
  • Power Tool
  • Hand tool
  • Shuttle Lift
  • Company Vechicle
  • Torch
  • Other

• Describe damages

• What is the make, model, year and license plate number of the company vehicle?

• Was local law enforcement called?

  Yes

  No

  N/A

• Name of the law enforcement agency the responded

• Was police report filed?

  Yes

  No

  N/A

• What is the case number?

• Was anyone else involved in the incident? Please list other driver information and include any other vehicles information including license plate, vin, make, model and year.

  Yes

  No

  N/A

• Name of person(s) involved

• Addresses of person(s) Involved

• Phone numbers of person(s) involved

• Property that was damaged that person(s) own or was using

• License plate or vin number or other identifying description of property

• Were there any witnesses?

  Yes

  No

  N/A

• Name of witness(es)

• Addresses of witness(es)

• Phone numbers of witness(es)

• Address where incident was located.

• Who owns the property that was damaged?

• What damages were caused?

• Nature and extent of the loss, damage or misuse.

• What actions have been taken to effect recovery or restitution?

• What is the estimate of repairs or replacement? 2 estimates are needed.

• Add photographs of the scene and damage

  Media

• Add media

  Media

• What Caught Fire?

• Was there property damage?

  Yes

  No

  N/A

• What was damaged?

  Select Crane/Cart Production Machine Hydraulic Pump Nissan or small forlift Taylor or large forklift Selick or medium foorklift Combi or side drive forklift Welder Ladder Power Tool Hand tool Shuttle Lift Company Vechicle Torch Other

  • Crane/Cart
  • Production Machine
  • Hydraulic Pump
  • Nissan or small forlift
  • Taylor or large forklift
  • Selick or medium foorklift
  • Combi or side drive forklift
  • Welder
  • Ladder
  • Power Tool
  • Hand tool
  • Shuttle Lift
  • Company Vechicle
  • Torch
  • Other

• Describe Other

• What Body Part was Caught?

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• What chemical were you exposed to?

• Body Part Exposed or Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• Side of Body injured

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• What chemical was spilled or released?

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• What side of the body was injuried?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the body was exposed to bloodborne pathogens?

  Yes

  No

  N/A

• What side of the body was exposed?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Was the fall from a height?

  Yes

  No

  N/A

• how far did the EE fall?

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• What happened that could have caused an incident?

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Was there a injury?

  Yes

  No

  N/A

• Body Part Injured

  Select Head Arm Leg Torso Foot Hand Finger Toes No injury

  • Head
  • Arm
  • Leg
  • Torso
  • Foot
  • Hand
  • Finger
  • Toes
  • No injury

• What part of the head was injured?

  Select Brain Eye Ear Teeth Skull Facial Bones Facial Soft Tissue Mouth

  • Brain
  • Eye
  • Ear
  • Teeth
  • Skull
  • Facial Bones
  • Facial Soft Tissue
  • Mouth

• What part of the arm was injured?

  Select Upper Arm Elbow Fore Arm Wrist

  • Upper Arm
  • Elbow
  • Fore Arm
  • Wrist

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the leg was injured?

  Select Upper leg Knee Lower Leg Ankle

  • Upper leg
  • Knee
  • Lower Leg
  • Ankle

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the torso was injured?

  Select Upper Back Mid Back Lower Back Chest Abdomen Shoulder Groin Buttock

  • Upper Back
  • Mid Back
  • Lower Back
  • Chest
  • Abdomen
  • Shoulder
  • Groin
  • Buttock

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the foot was injured?

  Select Foot Big toe 2nd toe 3rd toe 4th toe 5th toe (pinky)

  • Foot
  • Big toe
  • 2nd toe
  • 3rd toe
  • 4th toe
  • 5th toe (pinky)

• Was there an amputation?

  Yes

  No

  N/A

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• What part of the hand was injured?

  Select Hand Thumb Index 1st finger Middle 2nd finger Ring 3rd finger Pinky 4th finger

  • Hand
  • Thumb
  • Index 1st finger
  • Middle 2nd finger
  • Ring 3rd finger
  • Pinky 4th finger

• What side of the body was injured?

  Select Left Middle Right Not Applicable

  • Left
  • Middle
  • Right
  • Not Applicable

• Was there an amputation?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• In detail what excatly was the Employee doing right before the incident occured?

• Description of Incident in detail.

• In detail what did the employee do right after the incident?

• What Equipment was the Employee using before during and after the incident?

  Select Crane/Cart Production Machine Hydraulic Pump Nissan or small forlift Taylor or large forklift Selick or medium foorklift Combi or side drive forklift Welder Ladder Power Tool Hand tool Shuttle Lift Company Vechicle Torch Other

  • Crane/Cart
  • Production Machine
  • Hydraulic Pump
  • Nissan or small forlift
  • Taylor or large forklift
  • Selick or medium foorklift
  • Combi or side drive forklift
  • Welder
  • Ladder
  • Power Tool
  • Hand tool
  • Shuttle Lift
  • Company Vechicle
  • Torch
  • Other

• What PPE was the EE wearing during the time of the incident? Please list in detail all PPE

• Contributing Causes to Incident ( what do you think caused the incident to happen)

• Were all best practices being used?

  Yes

  No

  N/A

• What could you have done differently?

• Employee Signature

  Sign

• Date and Time

  Date

Leadership section

• Incident description ( In detail describe what happened as explained to you by the employee and witnesses)

• What contributing factors led to the incident

  Select Task Material Work Environment Employee Leadership

  • Task
  • Material
  • Work Environment
  • Employee
  • Leadership

• Was a safe work procedure used?

  Yes

  No

  N/A

• Had conditions changed to make the normal procedure unsafe?

  Yes

  No

  N/A

• Were the appropriate tools and materials available?

  Yes

  No

  N/A

• Were they used?

  Yes

  No

  N/A

• Were safety devices working properly?

  Yes

  No

  N/A

• Was lockout used when necessary?

  Yes

  No

  N/A

• Was there an equipment failure?

  Yes

  No

  N/A

• What caused it to fail?

• Was the machinery poorly designed?

  Yes

  No

  N/A

• Was the machinery maintained properly?

  Yes

  No

  N/A

• Were hazardous products involved?

  Yes

  No

  N/A

• Were they clearly identified?

  Yes

  No

  N/A

• Was a less hazardous alternative product possible and available?

  Yes

  No

  N/A

• Should personal protective equipment (PPE) have been used?

  Yes

  No

  N/A

• Was the PPE used?

  Yes

  No

  N/A

• Were users of PPE properly educated and trained?

  Yes

  No

  N/A

• Was PPE clean and serviceable?

  Yes

  No

  N/A

• What were the weather conditions?

• Was poor housekeeping a problem?

  Yes

  No

  N/A

• Was it too hot or too cold?

  Yes

  No

  N/A

• Was noise a problem?

  Yes

  No

  N/A

• Was there adequate light?

  Yes

  No

  N/A

• Were toxic or hazardous gases, dusts, or fumes present?

  Yes

  No

  N/A

• Was equipment properly inspected and maintained?

  Yes

  No

  N/A

• Did the worker follow the safe operating procedures?

  Yes

  No

  N/A

• Were workers experienced in the work being done?

  Yes

  No

  N/A

• Had they been adequately educated and trained?

  Yes

  No

  N/A

• Can they physically do the work?

  Yes

  No

  N/A

• Was EE using proper ergonomics to perform task?

  Yes

  No

  N/A

• Were they tired?

  Yes

  No

  N/A

• Was fatigue or shiftwork an issue?

  Yes

  No

  N/A

• Were they under stress (work or personal)?

  Yes

  No

  N/A

• Was there pressure to complete tasks under a deadline, or to by-pass safety procedures?

  Yes

  No

  N/A

• Did the EE violate Sabre policy or OSHA standard?

  Yes

  No

  N/A

• Was Horseplay involved?

  Yes

  No

  N/A

• Was the EE using all safety equipment and devices properly?

  Yes

  No

  N/A

• Did the EE report incident or injury immediately?

  Yes

  No

  N/A

• Were safety rules or safe work procedures communicated to and understood by all employees?

  Yes

  No

  N/A

• Were written procedures and orientation available?

  Yes

  No

  N/A

• Were the safe work procedures being enforced?

  Yes

  No

  N/A

• Was there adequate supervision?

  Yes

  No

  N/A

• Were workers educated and trained to do the work?

  Yes

  No

  N/A

• Had hazards and risks been previously identified and assessed?

  Yes

  No

  N/A

• Had procedures been developed to eliminate the hazards or control the risks?

  Yes

  No

  N/A

• Were unsafe conditions corrected?

  Yes

  No

  N/A

• Was regular maintenance of equipment carried out?

  Yes

  No

  N/A

• Had the condition or concern been reported beforehand?

  Yes

  No

  N/A

• Who was initially notified? (who in leadership was the first to know about the incident and arrive on the scene of the incidet?

• Who in EHS was notified?

• Date and Time EHS was notified

  Date

• Who responded to the incident? ( all responders that are not EHS)

• Who in EHS responded?

• Was Medical care needed?

  Yes

  No

  N/A

• Was first aid provided by a certified first aid responder?

  Yes

  No

  N/A

• Who was the first aid provider?

• Did the employee go for advance medical care outside the workplace?

• Was maintenance needed?

  Yes

  No

  N/A

• Who in maintenance was notified?

• Did Maintenance come to the scene?

  Yes

  No

  N/A

• When did maintenance arrive?

  Date

• Initial Cost of Incident Estimate

• What corrective actions are being taken?

  Select Elimination of hazard Substitutions Engineering Controls Administrative Controls (Signs, Training, Etc.) PPE

  • Elimination of hazard
  • Substitutions
  • Engineering Controls
  • Administrative Controls (Signs, Training, Etc.)
  • PPE

• Describe Elimination Plan

• Describe Substitution Plan

• What Engineering Controls will be put in place?

• What Administrative Controls will be performed? (Training, Signage Etc.)

• What PPE changes need to happen?

• Who is responsible for corrective actions

• When will corrective action be completed

  Date

• Is training going to be done?

  Yes

  No

  N/A

• What is the topic of training?

• Who is doing the training?

• When is training being done?

  Date

• What disciplinary actions is being taken?

  Select 1st Step Written 2nd Step Written Final Written Suspension Termination None

  • 1st Step Written
  • 2nd Step Written
  • Final Written
  • Suspension
  • Termination
  • None

• When is disciplenary action being taken

  Date

• When is disciplenary action being taken

  Date

• When is disciplenary action being taken

  Date

• When is disciplenary action being taken

  Date

• When is disciplenary action being taken

  Date

• Leadership Signature

  Sign

• Date and Time

  Date

EHS Section

• Did the EE receive advance medical care by ambulance, hospital emergency department, urgent care or clinic

  Yes

  No

  N/A

• What facility did they go to?

• When was advanced medical care given

  Date

• Did the employee have any procedure not listed on the OSHA 1st aid list?

  Yes

  No

  N/A

• What procedure or physician order was done outside of the OSHA scope of 1st aid?

• Did the EE receive a tetanus shot?

  Yes

  No

  N/A

• Was any diagnostic x-ray , cat scan or mri taken?

  Yes

  No

  N/A

• Did the EE take any over the counter medication?

  Yes

  No

  N/A

• What medication was given?

• Was any Rx medication given?

  Yes

  No

  N/A

• What was Rx to the EE?

• What was the treating physician's diagnosis?

• Did the EE RTW full duty?

  Yes

  No

  N/A

• What restrictions were placed on the EE?

• Was Physical Therapy ordered?

  Yes

  No

  N/A

• Is there an at work program that the EE can follow between appointments?

  Yes

  No

  N/A

• Was any drug testing done?

  Yes

  No

  N/A

• Why was testing not done?

• What was the results of the test?

  Non negative

  Negative

• Was HR Notified?

  Yes

  No

  N/A

• Who in HR was notified?

• Is there any follow up for the EE?

  Yes

  No

  N/A

• Where is the follow up?

• When Is the follow up?

  Date

• What physician is the EE following up with?

• Will the EE follow up on site with anyone before the follow up with physician?

  Yes

  No

  N/A

• Who will the EE follow up with?

• Was the employee admitted to the hospital for anything other than observation?

  Yes

  No

  N/A

• What was the admission diagnosis?

• Who is the doctor that ordered the admission?

• Incident Summary by step from injury to starting the task

• Body Part Injuried

• Equipment involved

  Select Crane/Cart Production Machine Hydraulic Pump Nissan or small forlift Taylor or large forklift Selick or medium foorklift Combi or side drive forklift Welder Ladder Power Tool Hand tool Shuttle Lift Company Vechicle Torch Other

  • Crane/Cart
  • Production Machine
  • Hydraulic Pump
  • Nissan or small forlift
  • Taylor or large forklift
  • Selick or medium foorklift
  • Combi or side drive forklift
  • Welder
  • Ladder
  • Power Tool
  • Hand tool
  • Shuttle Lift
  • Company Vechicle
  • Torch
  • Other

• Type of incident

  Select Property Damage Fire Caught Between Chemical Exposure Chemical Release Crush / Pinch Point Cut / Scrape / Laceration Electric Shock Exposure to Body Fluid or Infectious Material Slip Trip or Fall Frostbite Inflammation / Bruising Only Near Miss Strain or Sprain Struck by or against Traumatic Injury (Fx/ Dislocation) Workplace Violence

  • Property Damage
  • Fire
  • Caught Between
  • Chemical Exposure
  • Chemical Release
  • Crush / Pinch Point
  • Cut / Scrape / Laceration
  • Electric Shock
  • Exposure to Body Fluid or Infectious Material
  • Slip Trip or Fall
  • Frostbite
  • Inflammation / Bruising Only
  • Near Miss
  • Strain or Sprain
  • Struck by or against
  • Traumatic Injury (Fx/ Dislocation)
  • Workplace Violence

• 300 Log OSHA Recordable type

  Select First Aid Medical Only Restricted Lost Time Not an OSHA Recordable

  • First Aid
  • Medical Only
  • Restricted
  • Lost Time
  • Not an OSHA Recordable

• 300 Log OSHA Recordable Cause

  Select Rx Diagnosis Medical Procedure Splinting Wound Closure Physical Therapy Restriction Lost Time

  • Rx
  • Diagnosis
  • Medical Procedure
  • Splinting
  • Wound Closure
  • Physical Therapy
  • Restriction
  • Lost Time

• 300 Log OSHA Recordable Cause

  Select Rx Diagnosis Medical Procedure Splinting Wound Closure Physical Therapy Restriction Lost Time

  • Rx
  • Diagnosis
  • Medical Procedure
  • Splinting
  • Wound Closure
  • Physical Therapy
  • Restriction
  • Lost Time

• 300 Log OSHA Recordable Cause

  Select Rx Diagnosis Medical Procedure Splinting Wound Closure Physical Therapy Restriction Lost Time

  • Rx
  • Diagnosis
  • Medical Procedure
  • Splinting
  • Wound Closure
  • Physical Therapy
  • Restriction
  • Lost Time

• 300 Log OSHA Recordable Cause

  Select Rx Diagnosis Medical Procedure Splinting Wound Closure Physical Therapy Restriction Lost Time

  • Rx
  • Diagnosis
  • Medical Procedure
  • Splinting
  • Wound Closure
  • Physical Therapy
  • Restriction
  • Lost Time

• What is the severity (SE) of the injury or incident? (1-5)

• What is the frequency (FE) of the task? (1-5)

• What is the probability (PR) that the incident will happen again is nothing is done? (1-5)

• What is the likelihood of detecting or avoiding (AV) an incident before it occurs? (1-5)

• Risk Score ((SE*(FR+PR+AV)) (3-75)

• EHS Recommended Actions

• EHS Signature

  Sign

• Date and Time

  Date

Follow up

• Name of peron following up

• Has corrective actions been done?

  Yes

  No

  N/A

• What corrective action were completed?

• Who completed corrective actions?

• Completion date?

  Date

• Has trainging been done?

  Yes

  No

  N/A

• What form of training was done?

• Who did training?

• Training completion date?

  Date

• Was Disciplary action taken?

  Yes

  No

  N/A

• What was the level

• Completion date

  Date

• EHS Follow up signature

  Sign

• Time and Date

  Date