Environmental Engineering Reference
In-Depth Information
generAl AccIdent dAtA
2 of 5
WAS.A.COMPANY.OR.GOVERNMENT.SAFETY.RULE.VIOLATED.BY.THE.PRINCIPAL.OR.
OTHER.INDIVIDUAL(S).INVOLVED.IN.THE.ACCIDENT?
.
□
.YES.
□
.NO
CITE.THE.RULE._____________________________________________.CHECK.(.).WHEN.COMPLETED.
DESCRIBE.HOW.THE.RULE.WAS.VIOLATED:..___________________________________________
____________________________________________________________________________________
What.Were.Helpers.or.Co-Workers.Doing.at.the.Time.of.the.Accident?.. __________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Were.These.Normal.Activities?.
□
.Yes.
□
.No. If.“No,”.Explain:.._____________________________
____________________________________________________________________________________
____________________________________________________________________________________
Was.First.Aid.Given.to.Principal(s)?.
□
.Yes.
□
.No
By.Certiied.Person?.
□
.Yes.
□
.No
What.First.Aid.Was.Administered?.._______________________________________________________
____________________________________________________________________________________
Was.Principal.Accompanied.to.Emergency.Transportation,.Hospital,.or.Doctor?
.
□
.Yes.
□
.No. By.Whom?.. __________________________________________________________
Did.Principal.Complete.the.Shift.Prior.to.Seeking.Medical.Attention?
.
□
.Yes.
□
.No
How.Was.Principal.Assigned.to.Job?
. Bid.for.Job—Regular.Job.
□
. Assigned.by.Foreman.
□
. Assigned.by.Foreman,.Temporary.or.Replacement.
□
How.Much.Production.Was.Lost.as.a.Result.of.the.Accident?
_________.tons,.or._________.production.time.hours.
Is.There.Any.Reason.to.Question.the.Accuracy.of.the.Accident.Description.Given.by.Principal(s)?
Superviory.or.Witnesses?.
□
.Yes.
□
.No
Describe.Reasons:.. ____________________________________________________________________
