Laserfiche WebLink
Injury/Illness Report <br />PERSONAL PROTECTIVE EQUIPMENT (PPE) <br />Employee not using PPE <br />C' PPE Not Specified for Task <br />1-1 PPE Unavailable <br />Employee Not Advised of PPE <br />Employee Not Properly Trained in PPE <br />PPE Used Incorrectly <br />? PPE Inadequate <br />Emergency Equipment Not Specified (Shower, Eyewash, Etc) <br />Ll Emergency Equipment Not Available <br />? Emergency Equipment Not Used <br />? Emergency Equipment Malfunctioned <br />Other/Unknown <br />MANAGEMENT - Was a Management Defect a Contributing Factor? <br />Supervisor Failed to Detect/Anticipate/Report Hazardous Condition <br />Supervisor Failed to Detect/Correct Deviations from Job Procedure <br />I No Supervisor Review of Hazards and Job Procedures <br />J Supervisor Responsibility Not Defined/Understood <br />Supervisor Not Trained in Accident Prevention <br />i Failure to Initiate Corrective Action for Known Hazard <br />Other/Unknown <br />OCCUPATIONAL HEALTH - Was a Chemical or Physical Agent a Contributing Factor? <br />Physical Agent: <br />Noise, Vibration <br />? Temperature Extremes <br />Ionizing Radiation - X, Gamma, Beta, or Alpha Radiation <br />I Non-ionizing Radiation - Microwave, Laser, Ultraviolet, or Radio Frequency <br />? Ergonomic - Repetitive Motion Trauma, Inappropriate Lighting, Glare, Incorrect <br />or Insufficient Tooling, Benches, Seating <br />Chemical Agent: <br />? Solvents Solvent Name <br />'I Acid, Bases Acid or Base Name <br />Particulates Particulate Name <br />I 1 Other Toxic Chemicals Chemical Name <br />Biological Agent: <br />I Microorganism Microorganism <br />Insect Insect's Name <br />Animal Animal Species <br />Allergens Allergen Name <br />Health And Safety Program A-5 <br />19E-36