SHEC Form 0001-06-S08

Central Luzon Doctors' Hospital

SAFETY, HEALTH & ENVIRONMENT
Hospital Drive, San Vicente, Tarlac City 2300
Tel. No. 9820806 Fax: 9824430

ACCIDENT REPORT FORM

NAME OF EMPLOYEE AGE SEX DESIGNATION/TRADE

Kenneth
LENGTH OF EXPERIENCE LENGTH OF SERVICE DATE & TIME OF ACCIDENT LOCATION OF ACCIDENT

Weather condition at the time of accident Work environment at the site of accident

Cloudy Stormy Ambient Hot

Heavy Rain Sunny Cold Humid

Light Rain Dry Wet

SEVERITY OF INJURY TIME LOST

Emergency Treatment First Aid Hospitalize No. of Hours: No. of Days:

TYPE OF ACCIDENT

Body Reaction Fall Manual Handling or Lifting Other:

Caught in, under or in between Flying Object Stuck Against

TYPE OF INJURY

Abrasion Crush/Compression Inhalation Sprain/Strain

Amputation Cut Laceration Other:

Concussion Dislocation Puncture

Contusion/Bruise Foreign Body (Eye) Scald/Blister/Burn

INJURED PART

Abdomen Chest Face Hand Internal Nose

Arm Ear Feet Head Mouth Thigh

Back Eye Finger Hip Neck Other:

Please specify (if applicable): Left Right

BRIEF DESCRIPTION OF THE ACCIDENT

CAUSE OF INJURY

Electricity Hand Tools Stepping Against an Object

Fall of Person (Different Level) Hot or Corrosive Substance Striking Against an Object

Fall of Person (Same Level) Lifting Appliances Toxic Gas or Substances

Accident Report Rev 1.0 01.31.07 Page 1 of 3 by: R Pornobi

 Falling Objects Lifting Gear Transport

Foreign Body (Eye) Machinery Others:

UNSAFE CONDITION

Defective Protective Gear (PPE) Improper Procedure No Unsafe Condition

Design Defect Improper Ventilation Overloading

Improperly Guarded Inadequate Aisle Space, etc. Poor Housekeeping

Improper Illumination No Protective Gear (PPE) Slippery Surface

Others:

UNSAFE ACT

Horseplay Taking Unsafe Position or Posture Using Unsafe/Defective Equipment

Making Safety Device Inoperative Unsafe Loading, Placing or Mixing Others:

Operating Without Authority Using Equipment Unsafely

Working on Moving or Dangerous Equipment

PREVENTIVE MEASURES

EVALUATION
Loss Severity Potential Probability of Recurrence

Major Frequent

Minor Occasional

Serious Seldom

PROPERTY DAMAGE
Object/Equipment/Material Involved:

Extent of Property Damaged:

Not applicable

Estimated Accident Cost: DIRECT: INDIRECT:

MEDICAL INFORMATION
Date/Time Admitted to Hospital Name of Hospital

Attending Physician:
Physician's Diagnosis/Findings:

RECOMMENDATIONS

Back to Work Give Lighter Work Sent Home

Confinement at Hospital Rest at Home ______ working days Other:

Reported by: Date Prepared:

Ram
Safety Manager
Frey Fil

Reviewed by: Date Prepared:

Accident Report Rev 1.0 01.31.07 Page 2 of 3 by: R Pornobi

 YOUR NAME
Safety Officer / DOLE-BWC
Accre. No. 1033-160104C-195

Copy to: Hospital Admin, DOLE, HRMD

Accident Report Rev 1.0 01.31.07 Page 3 of 3 by: R Pornobi