Document jgRZQ870VdjxmE3JeG7LRK6j2

22 Personal protective equipment required' (Protective |um safety shoes safety hat safety belt)-- Wes mforatf usmg required equipment'--------------- ,------------------------------------ -- 23 What can be done to pitnewt a recurrence of ttws type of accident* (Modification of machine mechanical guards correct environment training) 24 Detailed narrative description (How did accident occur why objects equipment toots used circumstance assigned Ames Be specific)----------------------------------------------------------------------------------------------------------------------------------------------------------- --- 25 Witnesses to Occident (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 ill) person or others contnbuted to this acadent* b Your recommendation. Date. Signature of Superintendent FOR SAFETY OFFICE USE ONLY Temporary Total Permanent Partial Q Started losing time__________ _______ Returned to nHi Part of Body___ Per cent loss or loss of use- _ ______ Death or Permanent Total G Time charge_______ -- - Tima chary Time charge 6 000 days Compensation $Medical $Other S____________________________________________Total $ Name and address Name end address of hospital______________________________________________ of physician__ Cwf^OlN* mi Issued by NATIONAL SAFETY COUNCIL - 425 North Michigan Avenue - Chicago Illinois 60611 * MOMCOvcamcari su*ro*ico eustc iunci oKMU*ii nnwiwiwwii lOl Form IS-IS 2SM-S7301 PrtoWd UU SJL SWeSNo. taSJl Fic 6-2b --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 127