Provided emergency medical assistance to anyone who is injured or ill?| _ | _
| Taken any necessary emergency action to prevent further injury or property damage?| _ | _
| Secured the scene to preserve the evidence for study?| _ | _
| Taken photos or measurements, if needed?| _ | _
| Interviewed witnesses to determine what happened?| _ | _
| Interviewed others with relevant information?| _ | _
| Determined the cause(s) of the accident?| _ | _
| Made recommendations and action plans?| _ | _
| Filed other required reports?| _ | _
| | Does your record include the following information:
| Name of injured employee(s)| _ | _
| Accident date and time?| _ | _
| Nature and extent of injury/illness?| _ | _
| Exact location of accident scene?| _ | _
| Witnesses and their activities at the time?| _ | _
| Others with relevant knowledge?| _ | _
| Description of accident?| _ | _
| Description of events preceding accident?| _ | _
| Task/activity engaged in at time of accident?| _ | _
| Employees normally assigned task?| _ | _
| Length of employment and assignment to current job?| _ | _
| Relevant training received by employee and training dates?| _ | _
| Equipment/materials involved in the accident?| _ | _
| Physical surroundings of accident?| _ | _
| Unsafe acts that could have led to accident?| _ | _
| Description and dates of similar or related accidents?| _
| _ | Cause(s) of accident?| _ | _
| Actions taken to prevent similar accidents?| _ | _
| Additional recommendations?| _ | _
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