This is a report of a该事故属于: □ Death死亡 □Lost Time 损失工时 □Dr. Visit Only厂外就医 □First Aid Only 急救护理 □Near Miss虚惊 | |
Date of incident事故日期: | This report is made by报告填写人为: □Employee员工 □Supervisor主管 □EHS □Other其他_________ |
Step 1: Injured employee (complete this part for each injured employee)受伤人员（此项目每一位受伤人员一份） | ||
Name姓名: | 西游记主要内容50字 Sex性别: □Male男 □Female女 | Age年龄: |
Department部门: | Job title at time of incident受伤时的工作职位: | |
Part of body affected: (shade all that apply) 受影响的部位（涂黑） | Nature of injury受伤性质: (most rious one主要的一项) □Abrasion, scrapes摩擦刮伤 □Amputation 截肢 □Broken bone 骨折 □Brui 挫伤，青肿 □Burn (heat) 热灼伤 □Burn (chemical) 化学灼伤 □Concussion (to the head) 脑震荡 □Crushing Injury压伤 □Cut, laceration, puncture 割伤，切伤，刺穿伤 □Illness 疾病 □Sprain, strain扭伤，拉伤 □Damage to a body system: 身体系统损害 □Other其他 ___________ | This employee works: □Regular full time 全职 □Regular part time兼职 □Temporary临时工 |
Months with this employer工作年限 | ||
Months doing this job此工种年限: | ||
Step 2: Describe the incident事故描述 | |||
Exact location of the incident事故准确地点: | Exact time事故时间: | ||
What part of employee’s workday时间段? □Entering or leaving work上下班 □Doing normal work activities 日常作业 □During meal period就餐时 □During break休息时 □Working overtime 加班□Other__________ | |||
Names of witness (if any)目击者（如果有）: | |||
Number of attachments附件编号 | Written witness statements目击者笔录: | Photographs图片: | Maps / drawings图纸: |
What personal protective equipment was being ud (if any)佩戴了何种劳防用品? | |||
Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details. 详细描述事故经过。包括设备，零部件，物品，工具，材料和其他细节 Description continued on attached sheets: 下接附件： | |||
Step 3: Why did the incident happen? | |
Unsafe workplace conditions: (Check all that apply) 物的不安全的状态 □公公太大了Inadequate guard 防护装置不当 □Unguarded hazard 无防护的危害因素 □Safety device is defective 安全装置缺陷 □Tool or equipment defective 工具设备缺陷 □Workstation layout is hazardous 现场布局不合理 □元宵节日记200字Unsafe lighting 不安全照明 □查看和察看的区别Unsafe ventilation不安全通风 □Lack of needed personal protective equipment缺少劳防用品 □Lack of appropriate equipment / tools 缺少设备工具 什么花最好看□Unsafe clothing 不适当的穿着 □No training or insufficient training 未培训或培训不足 □Other其他: ____________ | Unsafe acts by people: (Check all that apply) 人的不安全行为 □Operating without permission未经许可作业 □Operating at unsafe speed 不安全作业速度 □集体安全Servicing equipment that has power to it □Making a safety device inoperative 使安全设备失效 □Using defective equipment 使用有缺陷的设备 □Using equipment in an unapproved way 违规操作设备 □Unsafe lifting 不当升举 □Taking an unsafe position or posture 不安全的姿势或者作业位置 □Distraction, teasing, horplay 嬉笑打闹 □Failure to wear personal protective equipment 不当佩戴劳防用品 □Failure to u the available equipment / tools 错误使用设备工具 □Other其他: ____________ |
Why did the unsafe conditions exist为何物的不安全状态存在? | |
Why did the unsafe acts occur为何人的不安全行为发生? | |
Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may have encouraged the unsafe conditions or acts是否存在鼓励不安全行为或不安全状态的公司政策或命令? □Yes □No If yes, describe如果有，请描述: | |
Were the unsafe acts or conditions reported prior to the incident之前是否有报告过该隐患? □Yes □No | |
Have there been similar incidents or near miss prior to this one 之前是否有类似的事故?□Yes □No | |
Step 4: How can future incidents be prevented?事故预防 |
What changes do you suggest to prevent this incident/near miss from happening again? 你觉得该如何改善以预防类似事件再发？ □Stop this activity停止此类作业 □Guard the hazard 防护隐患 □Train the employee(s)培训员工 □Train the supervisor(s)培训主管 □Redesign task steps重设作业步骤 □Redesign work station 重设作业位置 □Write a new policy/rule 编写新规定 □Enforce existing policy 严格执行现有制度 □Routinely inspect for the hazard例行检查 □Personal Protective Equipment个人劳防用品 □Othe其他r: ________ |
What should be (or has been) done to carry out the suggestion(s) checked above? 上述建议如何持续有效实施？ Description continued on attached sheets下接附件: |
| 形容老人的词 Step 5: Who completed and reviewed this form? (Plea Print)调查及审核 | |
Written by编写人: Department部门: | Title职位: Date日期: |
Names of investigation team members调查人: | |
Reviewed by审核: | Title职位: Date日期: |
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