Document 99N1k3BxpL7yLJjd3nwVRBZ27

jSSJSsSSB- SUPERVISOR'S ACCIDENT INVESTIGATION REPORT 1. Name of injured employee: 2. Clock#: ^3^ 3. Department: ^/)1>________________ 4. Shirt: - ____________ 5. Supervisor -JSjjV- TjO*s 6. Injury Date: - J CL ' 3-%' _________ 7. Time: 8. Date Report Sent to Dept: (LenT/f 9. 10. 11. 12. 13. 14. 15. Date Reported to Supervisor / 0 r 3_ Date Reported to Medical Dept.:__ iZ. Employee's Ape: Sex: `ffiMale 1 | Female dob when injured:____ Regular job/occupation: -- Lost Time:___________________ Medical only:__________----: 16. Where did accident occur. Plant: A/fifiDt t# S.T Exact location: (Machine #) (Area) Dept.#. SJL2- 17. i_ r 18. Specific iob beina oertcrmed at time accident' ^ i/LLTLk] r (uLny^ 7o fiAhZT ' 'f'W -/j '4**'*J- $l\ iaXtka~M t) -f- 19. Describe in detail how accident occurred and state what employee was doing when injured: , uOfiyw_____ tAA wi Aa 3Aruu___________________________ ________________ jiJr -e. , 'T7)KA/i CwA 3 tV CT-t(L (U^SlJLuLjP,v^. a t k/'k--p ` tlh/l-j / ft voiLo' ____ * 20. Check type of accident: Overexertion |--| Fall/slip same level j--| Fall/slip different level [--[ Struck against Stuck by | ) Caught between [ | Repetitive motion Contact with Other (explain): AAA. JLs/jrfpS USlA 21 A. Did an "unsafe condition" exist? (H "no" skip to #22A) 21B. What conditions of tools, equipment or job site caused or contributed to this accident? (ie. Broken or worn equipment, wet fjopr etc.) . .. *i i-'W /f . (AJCtO 'Y\.^ -uL. &~lK 2Mi Wnat caused or contributed to the above unsate condition? Check, ati that apply. Answer only if 21A applies. j } Caused by employee I | Detective thru normal use j j Detective thru abuse/misuse j 1 Satety inspection failure V* * Causeao^e' '.".an acove i-st.t*e,c,A' | j Housekeeoing 1 I Faulty design I i Faulty const'uctior A^-e, Z'fsfA'lfit soor preventive maintenance \ \ Ventilation detect 1 1 Caused oy otne* emoicvee vV. /. 0t 22A. Did the employee commit an "unsate act?*_____-------------- {If "no" skip to #23) 22B. What did the employee do, or fail to do, that caused or contributed to this accident? CiAVn,, [rL&A-Ms, JLti-JeX.r\----------------------------------------------------------------------------- - t 22C. What caused or influenced the above unsafe action(s)? Check aR that apply. Answer only if item 22A applies. GJ Unaware of hazard i \ Did not know safe procedure Low level job skM Caused other ftan above til 5 (k)r, AU, 0 ignored known hazard 0 Triad to save time Q Tried to avoid effort ___A/VCK l^AJl . 0 Tried to avoid discomfort 0 influenced action Q Fatigue influenced action n Other physical condition --SLJufj- J-\)------^2A_ -' 23. What action has been taken (X) or win be taken {V] to prevent recurrence? (Mark all that apply) Preventative instructionof others Job reassignmentofemployee Improvedinspectionofprocedure n Improvedcleanupprocedure 0 Job safety analysis ordered Ef'3tfaor(explain): _ J<&)r Setetyguerddevieemretted Pmiectiv*equipmentrequired . 0 TooVequipment.repairrreptaoe 0 BetterdesigrVconstrection Standards jobprocedure Correction otherthanabove 0 Ramstructionofpersonft) 0 Dtsciptine of person(s) involved JLiL b* -wtl ...so CM-^sr^r^T , --- 24. Describe details of corrective action taken or planned: 25. Person ftFsporfebleiorpfelneo^rrertive^ction: 26. Witness: ) fit y>V) __________ _ 27. Investigated by:y~j/V^-^7 f j SupervjJr's Signature 28. Reviewed by: (Department Manager): 29. Reviewed by Employee: (Date) 30. Plant Manager: a- 'T, Comments:__ 31. Date Routed to Plant Nurse: 32. Date Received by Plant-Nurse: /- r - ^ 33. Safety Manager: -// Member s Signature By: Initials S^L Initials ,j , <- Date Report Completion: // / . / SA1R2