Environmental Engineering Reference
In-Depth Information
generAl AccIdent dAtA
4 of 5
Communications.Available:
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2.Way.Radio
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Radio.Paging
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Dial.Telephone
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Paging.Telephone
. . . Distance.from.Accident.Site._________.ft
Delay.in.Emergency.Action.Caused.by.Communication.System,.From.Time.of.Accident:._________.minutes
Because.of:. Location.
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. System.Failure.
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. Incorrect.Use.
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Hard.Hat.Worn?.
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.Yes.
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.No. If.Involved.in.Accident,.Did.It.Fail?.
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.Yes.
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.No
If.Fainted,.Describe.How:.. ______________________________________________________________
____________________________________________________________________________________
Manufacturer:._________________________________________.Model:.________________________________________
Gloves.Worn?.
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.Yes.
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.No
Type.of.Gloves:. Leather.
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. Rubber.
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. Cotton.
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. Other.
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.(Specify).. _______________________
Condition.of.Gloves.if.Involved.in.Accident:.
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.Good.
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.Poor
Relationship.to.Accident.or.to.Injury:.._____________________________________________________
____________________________________________________________________________________
Type.of.Shoes.or.Boots.Worn:. Leather.
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. Rubber.
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. Man-made.materials.
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Hard.toe:.
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.Yes.
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.No. High.Top.(above.ankle):.
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.Yes.
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.No
Type.of.Sole:. Leather.
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. Hard.Rubber.
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. Soft.Rubber.
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. Plastic.
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Relationship.to.Accident.or.to.Injury:.._____________________________________________________
____________________________________________________________________________________
Hearing.Protection.Worn?.
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.Yes.
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.No
Type.of.Hearing.Protection:. Individual.Ear.Plugs.
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. Protective.Caps.or.Muffs.
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Manufacturer:._________________________________________.Model:.________________________________________
Properly.Worn?.
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.Yes.
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.No
Relationship.to.Accident.or.Injury:.._______________________________________________________
____________________________________________________________________________________
Eye.Protection.Used?.Safety.Glasses:.
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.Yes.
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.No
. Prescription:.
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.Yes.
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.No
Side.Protection:.
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.Yes.
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.No.
Failed?.
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.Yes.
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.No
