Environmental Engineering Reference
In-Depth Information
PrIncIPAl Person dAtA
2 of 4
Medication.in.Use.at.Time.of.Accident:.(Prescription.and.Non-Prescription)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Degree.of.Injury:. Fatal._________. Permanent.Disability._________.
Temporary.Disability._________. Minor.Injury._________. No.Injury._________.
Date.Returned.to.Regular.Job.at.Full.Capacity:._________/_________/_________
Number.of.Days.Away.from.Work:.._______________________________________________________
Number.of.Days.of.Restricted.Work.Activity:.._______________________________________________
Injury(s).or.Illness.From.Accident.(As.Deined.by.Principal,.Witness.or.Investigators):..______________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Is.It.Known,.From.the.Principal.Directly,.or.Through.Acquaintances,.That.the.Events.Below.Occurred.
in the.Principal's.Life.during.the.Week.(Approximately).Prior.to.the.Accident?.Check.Those.Which.
Apply..Explain.Briely.in.Space.Provided..Also.Note.Other.“Stressors”.Than.Those.Listed.Which.Apply.
.
.
□
Death.of.Spouse,.Child.or.Living.Partner
.
.
□
Death.of.Other.Family.Member
.
.
□
Divorce.or.Separation
.
.
□
Jail.Term
.
.
□
Personal.Injury.or.Illness,.On.Job.or.Off
.
.
□
Marriage,.Marital.Reconciliation,.or.New.Living.Partner
.
.
□
Retirement.Date.Set.and.Imminent
.
.
□
Change.in.Health.of.Family.Member
.
.
□
Pregnancy,.Self.or.Intimate.Acquaintance
.
.
□
Gain.of.New.Family.Member
.
.
□
Change.in.Financial.State
.
.
□
Death.of.Close.Friend
.
.
□
Change.in.Number.of.Arguments.with.Spouse
.
□
Foreclosure.of.Mortgage.or.Loan
.
.
□
Change.in.Responsibilities.in.Union
.
.
.
□
Son.or.Daughter.Leaving.Home
.
.
□
Trouble.with.Relatives
.
.
□
Outstanding.Personal.Achievement.at.Work.or.Elsewhere
.
.
□
Wife.Began.or.Stopped.Work.or.Being.Partner
.
.
□
Change.in.Living.Conditions
