事故報(bào)告表格格式

1、incident title事件標(biāo)題incident tracking number事件跟蹤號(hào)碼group集團(tuán)division部門sub division分部site where incident occurred事件發(fā)生地點(diǎn)air products premises? (yes or no)if no, indicate the exact addressapci工廠？(是或否)如果不是,請(qǐng)指明具體地址incident date事件日期incident time事件時(shí)間name of injured/ill employee受傷/生病雇員姓名age年齡job title職務(wù)time in j

2、ob function現(xiàn)崗位工作時(shí)間workplace of record (if different than site where incident occurred)可記錄的工作地點(diǎn)(如果與事件發(fā)生地點(diǎn)不一樣)group(集團(tuán)): division(部門): subdivision(分部): facility(工廠): home address家庭地址incident description事件描述immediate corrective action立即采取的改正措施.overnight hospitalization (yes or no)通宵住院治療(是或否)name and ad

3、dress of physician醫(yī)生姓名和地址name and address of hospital or clinic醫(yī)院或門診部的名稱和地址investigation start date調(diào)查開始日期process knowledgeable?對(duì)工藝有認(rèn)識(shí)的?investigation team調(diào)查組company/department公司/部門yes/no是/否witness name, address, phone number證人姓名，地址，電話號(hào)碼investigation summary調(diào)查小結(jié)1.was employee diagnosed with an occupat

4、ional illness?雇員是否被診斷為職業(yè)??？(i.e. hearing loss, cumulative trauma or repetitive stress injuries, etc.)(如：失聰，勞損或反復(fù)性壓力損傷，等)2.did injured employee lose consciousness?受傷雇員是否失去知覺？3.was prescription medication prescribed or supplied by physician for more than one dose application? if yes, identify prescript

5、ion/duration.醫(yī)生開出/提供的治療處方是否多于一劑？如果是，請(qǐng)說明處方劑量/持續(xù)時(shí)間。4.did injury involve 2nd or 3rd degree burns, cutting away dead skin, removal of foreign bodies from the eye by tweezers or scraping, a positive x-ray diagnosis or require sutures, butterfly bandage, or steri-strip(s)?是否為2級(jí)或3級(jí)燒傷，切除壞死皮膚，用鑷子從眼中取出其他物體或碎片

6、，確實(shí)經(jīng)過x光診斷或需要縫合，使用蝴蝶繃帶或消毒繃帶？5.were hot/cold soaks or compresses, whirlpool bath therapy, heat therapy or application of antiseptic required during second or subsequent visit to medical personnel?是否熱/冷浸泡或熱敷？渦流浴治療，熱療或當(dāng)?shù)诙位螂S后對(duì)傷者的探視中需要使用消毒劑？6.did injury/illness cause restriction of work or motion?受傷/疾病是否

7、導(dǎo)致工作或行動(dòng)受到限制？7.was employee transferred to another job because of injury/illness?是否因受傷/疾病該雇員轉(zhuǎn)換到其他的工作？8.did employee miss his/her next or subsequent scheduled workday due to injury/illness?該雇員是否因受傷/疾病而使得他/她未能在下一個(gè)或隨后的即定工作日上班？9.was injury/illness fatal to the employee?受傷/疾病對(duì)該雇員是否是致命的？10.recordability ty

8、pe (recordable injury, recordable illness, or first aid)可記錄的類型(可記錄的工傷事故，可記錄的疾病，或急救)11.recordability category (medical treatment, restricted duty, lost time, or fatality)可記錄的范疇(醫(yī)療治療，工作受限，失時(shí)工傷事故，或死亡)12.if a lost time incident, number of complete work days lost (estimate)如果為失時(shí)工傷事故，完全不能工作的天數(shù)(預(yù)計(jì))13.if a

9、restricted duty incident, number of restricted work days (estimate)如果為工作受限事件，受限的工作天數(shù)(預(yù)計(jì))14.describe treatment/therapy:處理/治療描述:note: if you answered yes to any of the first 9 questions, then the injury is probably recordable and must be recorded on the site osha 200 log within 6 days, pending final d

10、etermination. if medical treatment was (or should have been) provided and a yes answer was not logged, then consult your safety professional for determination of recordability.備注：對(duì)于前9個(gè)問題，如果你對(duì)任意一條的回答為“是”的話，則該工傷很有可能為可記錄的，并且在6天內(nèi)必須記錄在現(xiàn)場(chǎng)osha 200 log中等候最終的決定。如果施行了(或必須進(jìn)行)醫(yī)療治療，且未被記錄為“是”，則依照你對(duì)安全的專業(yè)知識(shí)來判定是否為可記

11、錄的工傷事故。answer yes or no to the following questions regarding factors that were directly involved at the time of the accident.在事故發(fā)生時(shí)，對(duì)下列與直接因素有關(guān)問題進(jìn)行“是”或“否”的回答：1.was air products product involved?與apci產(chǎn)品有關(guān)嗎？2.did the injured/ill person assume a risk previously identified as a hazard?傷者/病人是否在事故發(fā)生前已認(rèn)為有危險(xiǎn)

12、？3.was the injured/ill person wearing required protective equipment?傷者/病人是否已經(jīng)穿戴防護(hù)設(shè)備？4.was the injured/ill person engaged in horseplay/fighting?傷者/病人是否參與了嬉戲/打鬧？5.was the injured/ill person performing unauthorized work?傷者/病人是否未經(jīng)批準(zhǔn)進(jìn)行作業(yè)？6.was the injured/ill person rushed/in haste, under stress, or distracted?傷者/病人是否在匆忙中，在壓力下，或是在心煩意亂中貿(mào)然行事？7.did the injured/ill person appear to be under the influence of alcohol/drugs?傷者/病人是否在酒后/服食毒品后進(jìn)行作業(yè)？8.did the injured/ill person violate rules/permits/practices/regulations?傷者/病人是否違反了規(guī)章制度/操作條例？9.was the injured/ill person a victim of another workers actions?傷者