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APPENDIX B (Continued) <br /> Accident Causes (Circle All Appropriate Responses): <br /> Slip/Trip Fall from Elevation Fall from Same Level <br /> Overexposure Contact with Hot Item Contact with Electricity <br /> Flying Object Chemical Contact Weight <br /> Stepped On Hit by/Stuck by/Against Caught In/By/Between <br /> Pushing/Pulling Reaching Twisting <br /> Repetition <br /> Other: <br /> Nature of Injury(Circle All Appropriate Responses): <br /> Strain Sprain Cut/Laceration/Puncture <br /> Foreign Body Cumulative Trauma Burn Contusion <br /> Crushing Electric Shock Fracture <br /> Hernia Infection Inflammation <br /> Loss of Hearing Respiratory Irritation Stress <br /> Rupture Occupational Disease <br /> Other: <br /> Unsafe Acts and Unsafe Conditions <br /> List each unsafe act and condition. Review to determine whether training is adequate and <br /> accountability is in place. <br /> Unsafe Act Unsafe Condition <br /> 10275-4 <br /> D U D E K B-4 June 2017 <br />