Document 914O4j7wEKdXa10mq1xeXpNpq

DEPARTMENT SUPERVISOR'S ACCIDENT COST REPORT Date -- 6-23Name of injurcil wnrLir Thomas Black Injury Accident_________*-------------------No-Injury Accident------------------------------- 1 How many other workers (not injured) lost time liecause thev were talking, watching, helping at accident9 _____1______ 20About how much I.me did most of them lose9 _______D___ hours -- ------ minutes 2 How many other workers (not injured) lost lime because they lacked equipment damaged in the accident or because they needed the output nr aid of the injured worker9 3Q------- About bow much time did most of them lose9 . . Q . hours ------------------- minutes 3 Describe the damage to material or equipment HydraulxC cylinder crushed_Jb2_fork_ on lift truck. Cylinder scrapped and replaced with new .part.____________________ Estimate the cost of repair or replacement of above material or equipment $___280.00__ 4. How much time did injured worker lose on dav of mjurv for which he was paid?____2_ ______ hours --4^- _ minutes 5 If operations or machines were made idle Will overtime work probabU be necessary to make up lost production9 Yes No Q Will it lie impossildr to make up loss of use of machines or equipment9 Yes Q, No QJ Demurrage or other special non-*age costs due to stopping an operation S__1^8.00 (est.) 6 How much of supervisor's time *as used assisting, mvesticating. reporting, assigning *ork. training or instructing a substitute, or making other adjustments 1______ hours . -*30 minutes Name of supervisor__________ AXan_Hoskin_, Fill in and send to the safet* department not later than da\ after accident vtock *lo 1? 2? Published by National Safetv Council 425 North Michigan Avenue Chicago Illinois 60611 I 111 s\ I *m IN" R j. *M*. -> i Fic 7-3 --Hiis cost form (88 X 11 in ) should be prepared by the department supervisor as soon after the accident as information becomes available on the amount of time lost by all persons and the extent of damage to product and equipment 165