テンプレート Construction Dome construction accident :: incident report checklist Dome construction accident :: incident report checklist このフォームの内容 このフォームには48つのセクションがあります： Report Prepared By Select date Date Phone Number InformationContacted Safety Officer Name of Safety Officer Jobsite Name Add location Address Project Manager Superintendent Foreman Safety Coordinator Employee Name SSN# DOB Date Address Home Phone Number Date of Hire Date Job Title End Time Exact Location Of Incident (Bldg/Leve/Area) General Task At Time Of Incident (i.e. Moving Strut) Specific Activity At Time Of Incident (i.e. Bending Over To P/U Strut) Date and Time of Incident Date Day Of Week Date Reported to Dome Date Reported to Whom at Dome Type of Injury Part of Body Injured #3 Injury / Illness InformationWas First Aid GivenWas Employee Taken to a Medical Facility Offsite Employee's Supervisor Name Designation Describe in detail the circumstances of the incident (attach diagrams, drawings and/or photos of accident scene). Give chronological sequence of events. If materials and/or equipment were involved, start before the materials/equipment were brought to the incident scene describing who, what, where, when, how: #5 Description of the Incident (not to be completed by the injured worker)Attach Photo The following is a summary of events Name of witnesses and others working with injured worker (include statements with report) Objects, substance, equip. involved in incident (desc/model/serial #) List PPE worn at time of incident Safety equipment & training required for job #6 Additional InformationDoes employee normally operate this equipmentWas employee instructed in the safe use of this equipment Describe in detail & include copies of equipment certifications When/How was this rule, regulation or specific instruction communicated to the injured worker(s) Corrective action(s) and completion date(s) Date of next scheduled toolbox safety meeting Date Name of leader #7 Corrective Action PlanHas the meeting leader been provided with this information for discussion Safety Officer: Frank Zamora, Email: Frank@domeconst.com Human Resource Director: Virginia Preciado, Email: Virginia@domeconst.com 類似のテンプレート General first aid kit checklist Sopralluogo in azienda checklist Cleaning room checklist Delica domestic arrival qc report asparagus checklist Lih pre start risk assessment checklist Housekeeping & gmp audit このテンプレートを使用