Document 6BogDkz5eX8Vy23QyjOvR7N24

13 HOW DID THE ACCIDENT OCCUR? (Describe fully the events) OCCUPATIONAL INJURY OR ILLNESS 14 DESCRIBE THE INJURY OR ILLNESS * detail and mdceta the part of the body affected a AGENCY (Objector substance mvotved) ACCIDENT AGENCY (1st column) The first object or substance involved (A accident sequence INJURY AGENCY (2nd column) The agency inflicting the injury Sae alio taction IS (Example Worker fed from ladder and struck head on machine Check Ladder4 under accident and check Madam* under injury) ACCIDENT INJURY (Check one bos m each column) 414* 01 (3 a to ojQ <* D - 10 r?-a oi Q Machine 03 0 Conveyor elevator hoist 03 Q Vehicle Oi 0 Electrical apparatus 09 0 Hand tool os 0 Chemical 67 0 Working surface bench table etc ot 0 Floor walking surface o 0 Bndcs rocks stones to 0 Box barrel container (empty or fuff) n 0 Door window etc 13 0 ladder 13 0 Lumber woodworking materials u 0 Metal is 0 Stairway steps 14 0 Other 17 0 Unknown is 0 None 6 ACCtOEWT TYTT. (First event n the accident sequence) h- 4f.jo oi 0 Fell from elevation to 0 Fan on tame level 03 0 Struck eoamst o< Q Struck by es 0 Caught in under or between oo 0 Rubbed or abraded o7 0 Bodily reaction oo 0 Overezertion or 0 Contact with electncel current to 0 Contact with temperature extremes it 0 Contact with radietioni caustics tone end noxious substances u O PuM* transportation euudem i) 0 Motor wtncie acodent u 0 Other is 0 Unknown ANSI Z16 1 INFORMATION A DEGREE OF USABILITY UNDER Z16.1 > oo i 0 Not e recordable case under 216 1 2 0 Temporary total disability 2 Q Permanent partial ditabUtty 4 Q Permanent total disability 50 Fatality W B OATS CHARGED UNDER 216.1 oi-64 a NATURE OF INJURY OR tUNESS (Check most enoue one) J) a. oi O Amputation <a 0 Bum and scald (heat) os Q Bum (chem cal) ot 0 Concussion os 0 Crushing injury 04 0 Cut lacerahon puncture abrasion or Q Fracture oo 0 Hernia or 0 Bruise contusion io 0 Occupational illness n 0 Sprain strain ia 0 Other b PART OP BODY (Chad mod temwi one) Uk Oi 0 Eyes e* 0 Heed lace neck 03 0 Beck os 0 Trunk (except back, internal) os 0 Aim as 0 Hand and wnst er Q Fingers oe 0 Le o 0 Feet and ankles ip 0 Toes it 0 Internal and other 15 NAME THE OBJECT OR SUBSTANCE WHICH DIRECTLY INJURED THE EMPLOYEE- Also check one box in mjury column under 13a 16 DATE OP INJURY OR INITIAL DIAGNOSIS OP OCCUPATIONAL ILLNESS a MONTH 43-s* cj 0 Jen oaQ Feb 03 0 March osQAprd 050 May os 0 June 0 July os 0 Aug or0 Sept io0 Oct ii 0 Nov 13 Q Oee b DATE OF MONTH 17 DtO EMPLOYEE Ot* 9* 0 Tes 30 No Date of Death. OTHER 18 NAME AND ADDRESS OF PHYSICIAN______________________ 19 IF HOSPITALIZED NAME AND ADDRESS OF HOSPTTAL Fic 6-3 DATE OF REPORT_________________________________________ __ PREPARED BY____________________________________________________ OFFICIAL POSITION NSC will use for statistics only and hold report confidential National Safety Council Printed m USA 0612 72 129