Environmental Engineering Reference
In-Depth Information
AccIdent dAtA, slIP or FAll oF Person
.(1).Slipped.on.what?/Fell.from.what?.._____________________________________________________
. . Fell.onto.what?/Fell.how.far?..________________________________________________________
.(2).Activity.when.slip.or.fall.occurred:..____________________________________________________
. . . ________________________________________________________________________________
.(3).Location.within.mine/plant/ofice:.. ____________________________________________________
. . . ________________________________________________________________________________
.(4).Equipment.or.machine.involved?.
□
.Yes.
□
.No. Type:..
. . Manufacturer:.. ____________________________________________________________________
. . Model:._____________________________________________.Area.of.machine.involved:..________________
.(5).Surface:. _________.Concrete.loor. _________.Ground. _________.Steel.plate
. . _________.Metal.grate. _________.Other.Describe:.. ________________________________________
. . Surface.condition:.._________________________________________________________________
.(6).Depth.of.irregularities:.. _____________________________________________________________
. . Sketch.accident.site.
.(7).Does.lighting.at.accident.site.reveal.surface.conditions?.
□
.Yes.
□
.No
. . If.so,.explain:.._____________________________________________________________________
. . . ________________________________________________________________________________
.(8).Were.foot.and.hand.holds.adequate?.
□
.Yes.
□
.No.
If.not,.explain:
.
. . ________________________________________________________________________________
.
. . ________________________________________________________________________________
