ARCHIVED REPORTS_2016_1 - Laserfiche WebLink

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IINCIDENT ❑ Being hit by moving objects ❑ Contact or exposure to heat and cold ❑ Contact with electricity ❑ Contact with/or exposure to biological factors ❑ Exposure to mechanical vibration ❑ Exposure to mental stress factors ❑ Exposure to particles or contaminants ❑ Exposure to radiation ❑ Exposure to sharp,sudden sound ❑ Exposure to variations in pressure—other than sound *Mechanism: ❑ Falls from height ❑ Falls on the same level—including trips and slips ❑ Hitting objects with part of a body ❑ Long term contact with chemical or substance ❑ Long term exposure to sounds ❑ Repetitive movement with low muscle loading ❑ Pinch points ❑ Slide or cave-in ❑ Single contact with chemical or substance—excludes Vehicle accident insect and spider bites ❑ ❑ Unspecified mechanism or injury/illness ❑ All others: ❑ Biological Source ❑ Chemicals ❑ Human Source ❑ Indoor environment ❑ Live animals ❑ Machinery and fixed plant ❑ Mobile plant ❑ Non-living animals *Source of Injury ❑ Non-metallic substances ❑ Non-physical source ❑ Non-powered equipment ❑ Non-powered hand tools ❑ Outdoor environment ❑ Powered equipment,tools and appliances ❑ Road transport ❑ Underground environment ❑ Unspecified source ❑ Other: Information about the Physician or other Health Care Professional Name of Physician or other Health Care Professional: Facility where treatment given: Street Address: City: State: Zip Code: Was employee treated in emergency room? ❑Yes ❑No Was employee hospitalized overnight as an in-patient? ❑Yes ❑No Information about the Case Time the employee began work: What was the employee doing before the incident occurred? How did the injury occur? What was the injury or illness? What object or substance directly caused harm? If fatality,date of death: ENVIRONMENTAL (IF APPLICABLE) *Required Fields *Type Of Ecological Loss ❑ Fauna ❑ Flora ❑ Habitat/Wetland ❑ Archaeological ❑ Other If Other Type of Ecological Loss,please Impact Initiating Event: If other Impact Initialing Event,please specify specify: Contaminants(Spill or Release Only) Contaminant type: Volume release(number): Volume recovered(number): Sensitivity type: Unit: Unit: Unit: