REVIEW OF EMPLOYEE ACCIDENT

Name______________________________Position____________Div./Dept.________
Age_____________ Date of Injury_________________________
Nature of Injury_________________________________________________________
Cause of Injury__________________________________________________________
______________________________________________________________________
Possible length of disability________________________________________________

ANALYSIS OF CAUSE
INSTRUCTIONS UNSAFE PRACTICE POOR HOUSEKEEPING
( ) None ( ) Taking Chances ( ) Improperly pilled
( ) Not Enforced ( ) Short Cuts ( ) Congestion IMPROPER PLANNING
( ) Incomplete ( ) Haste ( ) Material lying about ( ) Layout of operation
( ) Erroneous ( ) Other (pls. Specify) ( ) Bad containers ( ) Layout of machines
( ) Others (pls.Specify) ___________________ ( ) Others ( pls. Specify) ( ) Unsafe processes
______________________ ___________________ ( ) Lack of equipment
PHYSICALLY UNFIT
INABILITY OF EMPLOYEE ( ) Lack of rules
( ) Defective DEFECTIVE EQUIPMENT
( ) Inexperienced ( ) Others (pls.Specify)
( ) Fatigued ( ) Misc. Materials
( ) Unskilled __________________
( ) Weak & Equipment
( ) Ignorant ( ) Sick ( ) Tools MENTALLY UNFIT
( ) Poor judgment ( ) Others (pls. Specify)
( ) Others ( pls. Specify)
( ) Machines ( ) Sluggish – fatigued
_______________________ ( ) Lack of maintenance
____________________ ( ) Violent temper
IMPROPER WORKING
( ) Poorly made ( ) Excitability
LACK OF CONCENTRATION CONDITIONS ( ) Not apparent ( ) Sick
( ) Attention distracted ( ) Ventilation ( ) Others ( pls.Specify) ( ) Home troubles
( ) Inattention ( ) Sanitation _____________________ ( ) Others (pls. Specify)
( ) Thoughtlessness ( ) Light
UNSAFE BLDG. CONDITIONS IMPROPER DRESS
( ) Other ( pls. Specify) ( ) Temperature
( ) Fire protection ( ) No goggles, gloves,
___________________ ( ) Others (pls. Specify)
( ) Exits masks
___________________
( ) Floors ( ) Unsuitable long
POOR DISCIPLINE
PHYSICAL HAZARDS
( ) Openings sleeves
( ) Disobedience of rules
( ) Ineffectively guarded ( ) Miscellaneous ( ) Defective shoes
( ) Interference of others
( ) Unguarded ( ) Others (pls. Specify) ( ) Failure to wear
( ) Fooling
( ) Guards Removed ____________________ safety shoes
( ) Disregarded
instructions ( ) Guards tampered with ( )Others (pls. Specify)
( ) Others ( pls. Specify) __________________
( ) Others ( pls. Specify)
________________________
____________________

What action by supervision might have prevented accident?___________________________

___________________________________________________________________________
___________________________________________________________________________
What action to be taken to prevent recurrence?_____________________________________
___________________________________________________________________________
___________________________________________________________________________
Made out by ________________________ Date ______________
Signature___________________________