Document Jrd7qKbQnZ2qxp88xZ5L4qbwZ

22 Personal protective equipment required7 (Protective glasses safety shoes safety hat safety belt). Was injured using required equipment7------------------ ---------------------------- --------------- ---------------------- 23 What can be done to prevent a recurrence of this type of accident7 (Modification of machine mechanical guards correct environment training) 24 Oetailed narrative description (How did accident occur why objects equipment tools used circumstance assigned duties Be specific)______________________________________ ________________________________________________ 25 Witnesses to accident. (Use additional sheets as required) Date prepared________________________- Signature of Foreman/Supervisor----------------------------------- Department_______ -- --____ _________ SUPERINTENDENTS APPRAISAL AND RECOMMENDATION a In your opinion what action on the part of injured (or Ul) person or others contributed to this accident7 b Your recommendation. Date__ Signature of Superintendent FOR SAFETY OFFICE USE ONLY Temporary Total Permanent Partial Started losing time______ __________ Returned to worte _ Part of Andy Per cent loss or loss of us* Time charge. Time charge. Compensation *----- Name and address of hospital___________- - - *fi $Other $__________________________ Name and address of physician Death or Permanent Total Time charge 6 000 days Tti $. O1*** nn Issued by NATIONAL SAFETY COUNCIL 425 North Michigan Avenue Chicago Illinois 60611 A ftOWCOVt*NMlNTAl MMVATllT SUAAOKTCO FUSllC USVtCl O*OAUAT0M Form IS-IA JStt S7S0J PrtoM to USA. 8tack Ho tftSI Fig ll-2b --Central portion is filled in by higher level of management Bottom portion of form is filled in by the safety department (as the facts become available) and contains data for computing injury rates and costs 247