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Injury/Illness Report <br />Section 3 - Evaluation-of Accident, Illness or Incident <br />Body Part Affected (circle all that are applicable): <br />Abdomen Ear Head <br />Ankle Elbow Heart <br />Arm Eye Hips <br />Back Face Kidneys, Intest. <br />Brain Finger Knee <br />Chest Foot Leg <br />Digestive Hand Lungs <br />Injury Type (circle al l that are applicable): <br />Amputation Contusion Elec. Shock <br />Asphyxia Crush/Bruise Fracture <br />Burn/Chemical Cut/Puncture Freezing <br />Burn/Heat Dermatitis Hearing Loss <br />Concussion Dislocation Hernia <br />Injury Source (circle all that are applicable): <br />Air Pressure Clothing Heat <br />Animals Coal/Petroleum Hoists <br />Animal Product Cold Infectious <br />Body Motion Drugs & Agents <br />Boilers Medicines Ladders <br />Boxes/ Electricity Liquids <br />Containers Fire/Smoke Machines <br />Buildings/ Food Products Molten Metal <br />Structures Furniture Miner/Metallic <br />Ceramics Glass Minerals/ <br />Chemicals Hand Tool Nonmetallic <br />Accident Type Code (circle all that are appl icable): <br />Struck Against Fall on Same Rub/Abrasion <br />Struck By Level Bodily Reaction <br />Fall From Caught In/ Overexertion <br />Elevation Between Electrocution <br />Health And Safety Program <br />Multiple <br />Musc. Skel. <br />Neck <br />Nervous Sys. <br />Scalp <br />Shoulder <br />Skull <br />Heat Stroke <br />Infect. Disease <br />Inflammation <br />Multiple <br />Occ. Disease <br />Noise <br />Paper <br />Particles <br />Plants <br />Plastics <br />Power Tools <br />Power Trans. <br />Apparatus <br />Pumps <br />Radiating <br />Substances <br />Temp. Extremes <br />Radiations/ <br />Caustics <br />Public Transport <br />Thigh <br />Toe <br />Wrist <br />Other _ <br />Unknown <br />Poisoning <br />Radiation <br />Scratch <br />Sprain/Strain <br />Other _ <br />Unknown <br />Soaps <br />Silica <br />Scrap/Debris <br />Steam <br />Textiles <br />Vehicles/ <br />Forklifts <br />Wood <br />Working Surfaces <br />Other <br />Unknown <br />Motor Vehicle <br />Other <br />Unknown <br />A-3 <br />19E-34