Laserfiche WebLink
Hazardous Conditions (circle all that are applicable): <br />InjuryAllness Report <br />Defects in Dress/Apparel Inadequately Placement Hazards Other <br />Environmental Hazards Guarded Work Public Hazards Unknown <br />Hazardous Procedures Environment None <br />Accident Part Code (circle all that are applicable): <br />Parts of Boilers Parts of Conveyors Hand Tools Parts of Vehicles None <br />Parts of Buildings Parts of Hoists Power Tools Machines <br />Other <br />Place a check in the box of each factor that applies to this incident. <br />EQUIPMENT - Was a Hazardous Condition a Contributing Factor? <br />Lj Defect in Equipment/Tools <br />J Hazardous Condition Not Recognized <br />Hazardous Condition Not Reported <br />Employee Not Informed/Job Procedure Not Specified <br />? No Equipment Inspection Procedure <br />Inspection Procedure Failed to Detect Hazard <br />Correct Equipment/Tools Not Used <br />1 l Correct Equipment Not Available <br />0 Employee Not Informed of Correct Equipment <br />[J Substitute Equipment <br />Equipment Design Contributed to Operator Stress/Error <br />C Design/Quality of Tool Contributed to Hazardous Condition <br />11 Other/Unknown <br />ENVIRONMENT - Was the Location/Position of Equipment, Materials, or Employee a Contributing Factor? <br />1 Location/Position Contributed to a Hazardous Condition <br />Hazardous Condition Not Recognized <br />Hazardous Condition Not Reported <br />Employee Not Informed of Correct Job Procedure for Hazard <br />Employee Did Not Belong in the Area <br />Hazardous Condition Not Visible to Employee <br />? Insufficient Workspace <br />11 Poor Environmental Control <br />-l Uncontrolled Release of Hazardous Material <br />Other/Unknown <br />PEOPLE - Was the Job Procedure(s) a Contributing Factor? <br />Aggravation of a Pre-existing Condition <br />No Written/Known Procedure <br />i Job Procedure Inadequate <br />Employee Not Trained on Proper Job Procedure <br />Employee Deviated from Proper Job Procedure <br />Employee Not Physically/Mentally Capable of Performing Job <br />Job Procedure Too Difficult <br />1 Job Procedure Encourages Deviation <br />F1 Other/Unknown <br />Health And Safety Program <br />A-4 <br />19E-35