Environmental Engineering Reference
In-Depth Information
tABle 7.5
Accident report Form
DEPARTMENT:
EMPLOYEE.NAME:
LOCATION.OF.ACCIDENT:
DAT
E.OF.ACCIDENT:
EMPLOYEE.AGE:
ACCIDENT.TYPE:
TIME.OF.ACCIDENT:
EMPLOYEE.OCCUPATION:
ACCIDENT.CLASSIFICATION:
DESCRIPTION.OF.ACCIDENT/INCIDENT:. _______________________________________________________________________________________________
. _______________________________________________________________________________________________
. _______________________________________________________________________________________________
Item.Personal.Injury.Involved:..____________________________________________________________________________________________________________
Itemize.Property.Damage.Involved:.. _______________________________________________________________________________________________________
Item.Tools/Equipment.Involved:..__________________________________________________________________________________________________________
DIRECT
INDIRECT
BASIC
Inadequate.Policy.
and/or.Decisions
Environmental.and/or.
Personal.Factors
Energy.Source
Hazardous.Materials
Unsafe.Acts
Unsafe.Conditions
