Environmental Engineering Reference
In-Depth Information
generAl AccIdent dAtA
1 of 5
TIME.WORK.SHIFT.STARTED:._________.AM/PM
TIME.PRINCIPAL(S).BEGAN.WORK.ON.JOB.IN.WHICH.ACCIDENT.OCCURRED:.________.AM/PM
EXACT.TASK.AND.ACTIVITY.WHEN.ACCIDENT.OCCURRED:..___________________________________
____________________________________________________________________________________
WHAT.DIRECTLY.INFLICTED.THE.INJURIES.(IF.ANY):..__________________________________
____________________________________________________________________________________
MACHINERY.AND.TOOLS.INVOLVED:
tyPe
mAnuFActurer
model no.
serIAl no.
Description.of.Damage.to.Equipment.and.Estimate.Cost.to.Repair/Replace.in.Manhours.(detail):
____________________________________________________________________________________
____________________________________________________________________________________
Warning.Time.From.First.Sign.of.Imminent.Danger.to:
. Injury.Producing.Event.. ______________________________________________________________
. First.Available.Avoidance.Activity..______________________________________________________
Were.Principal(s).or.Helper(s).Working.Under.Pressure.to.Complete.Job.Rapidly?
.Yes. .No. If.“Yes,”.Explain:.. _______________________________________________________
Were.Proper.and.Safe.Tools.Available.for.the.Job?. .Yes. .No
Were.They.Used?. .Yes. .No. If.“No,”.Explain:.. _______________________________________
____________________________________________________________________________________
 
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