Injury and Illness Incident Report

Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes,_

U.S. Department of Labor

Oecupjrtlonal Salrty »nrf NhINi Administration

This Injury and Illness Incident Report is one: of the first lorms you must ilII out when a recordable work-related injury or illness lias occur red. Together with tilt* Log of Work'Relaltd injuries and itinessts and the accompanying Sttrnmaiy, these forms help the employer and OSHA develop a picture of the extent and severity of work-related incidents.

Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must lill ont this lor m or an equivalent. Some slate workers' compensation, insurance, or oilier reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the information asked for on this limn.

According to Public Law 91-596 and 29 CFR 1904, OSHA's recordkeeping rule, von must keep this form on file lor 5 years following the year to which it pertains.

If you need additional copies of this form, you may photocopy and use as many as you need.

Informa tion about the employee


Information about the physician or other health care professional

Njirtr ut phj'uf ¡to or lirallh I jir pnifmuoiul

It Imlmnil was given away fnrtn the worfcMle, where »» il given?

Information about the case tO) Cave number from the Loff 10 Doirnf injury or llliu%t I!) Time employee began work

Korm apjmvrcdOMIt no. m«4l76

rrfnm Ihr ÎAg h/1rr tun rrrmJ en

13) Time or ci


A\l PM D Check if ti be determined

H) What w*s Hh efflpfoy«« doing just bo for« tfw incident occurred? Dcscribe the activity, » well a« the IqqU, equipment, nr material the employee wax minrç. Br specific. Examples: "climbing a ladder while tarryirtg roofing materials"; "spraying chlorine front hand i|iray(t": "daily CûiMpuKr kcy-L-|Hry,"

ad?TriI u.ü Itmv the injury occurred. fixamp/ex: "When ladder xlipprd on wet floor, worker fell 20 fe«") "Worker wis sprayed »villi chlorine when gasket broke during replacement"; "Worker developed wrenfw in wrist over lime."

I®) What was the injury or tftrwaa? "lirLt ux ihc pun of the tutdj more xprcific than "hurt," "pain," or " sort'-" Example*: "str, tunnel syndrome."

that wax affected and him' il h<u affected; I inecf hack'"'; "'chemical burn, hand"; "carp:

Wax Miipliiy«- irriiti-d in an emn^riw y room?

Wax employee hospitalized overnight i< an in-patient? □ *«

17) What objcct or substance directly harmed the employee? Example*: "concrete floor"; "chlorine"; "radial arm saw." ff ¡hit que it tint does ml ripply to the incident, leave it blaut.

18) it the employ»« died, when dtd death occur? Dale at death

Public rc|H>rtmK binden fiir th in iJk-<t«iiMifiMji>i malum ¡» rMnnatcd U»av eoOeclkm cirinfnroiatkm unk» it iln|tliv. a current valid ( »MB control nui inlüiitfhifi, Ik; SOS 10. Ih> Iiu< kimI ihr ïimipk-iLiI luiini 10 ihii oflk v.

lung exoting data mine«, gullirring and maintaining Ihr data needed. and completing ami revkiring tlic rvHcilioii ot inlni maliou IVrwm arc a>]Kcti oi üi» daia c«]|ectkm. including lUggeMioi» liw reducing i Im binden, mittuet: L S Department c-f l-ubar. OSHA tMBce uf Siaiitlkal Ajialvtit. Rwm N-5-

I. ÜOöCniHtitiitiuti Avenue. NW.

Exhibit 5-33

OSHA form 301.

Exhibit 5-34

Accident report.

Company Name Address City, State, ZIP Phone Number

Name of injured: ,

Contractor: _

Project Name:

Social Security # _

Home address of injured:

How long?

What was person doing at time of injury? . Where and how did the accident occur? _

Specify machine, tool, substance, or object that directly injured employee:

Was medical treatment sought? Yes__No

Was person unable to work after injury?____

If yes, for how long was he absent from job?___

List names and addresses of witnesses:___

Describe any unsafe acts or conditions contributing to accident:__

Explain specifically the corrective action taken:

CM/GC's records. The evaluation procedures do not stop with filling out the forms. The PM, Safety Director, superintendent, and subcontractor must now analyze the cause of the accident. In addition, OSHA and the local and state building departments may perform their own investigation of the accident. Once the cause is found, new procedures must be implemented immediately to eliminate any potential similar accidents. In addition, all the trades people on site must be made aware of the new procedures. In addition, the safety meetings must reemphasize proper safety standards. The old philosophy that this accident will not happen to me and therefore I do not have to follow safety guidelines must be eliminated from the psyche of all the trades people working on site. Continuous safety training, site walking by the safety director, and numerous signs (see Exhibit 5-35 for a typical safety sign) are the only ways that accidents can be prevented.


Exhibit 5-35

Hard hat sign.

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