Environmental Engineering Reference
In-Depth Information
generAl AccIdent dAtA
5 of 5
If.Failed,.Describe.How:.. _______________________________________________________________
Relationship.to.Accident.or.Injury:.._______________________________________________________
____________________________________________________________________________________
Respirator.Used?.
□
.Yes.
□
.No
Portable.Breathing.Apparatus?.
□
.Yes.
□
.No
If.Involved.in.Accident.or.Injury,.Describe.How:..____________________________________________
____________________________________________________________________________________
Relationship.to.Accident.or.Injury:.._______________________________________________________
____________________________________________________________________________________
Manufacturer:._________________________________________.Model:.________________________________________
Personal.Flotation.Device.Worn.at.Time.of.Accident?.
□
.Yes.
□
.No
Manufacturer:._________________________________________.Model:.________________________________________
Relationship.to.Accident.or.Injury:.._______________________________________________________
____________________________________________________________________________________
Safety.Harness.and.Lifeline.in.Use.at.Time.of.Accident?.
□
.Yes.
□
.No
Type:._________________________________________.Condition:._____________________________________________
Relationship.to.Accident.or.Injury:.._______________________________________________________
