HomeSafetyClassification/Treatment Classification/Treatment Classification/Treatment Classification/Treatment (Please select level and check one item below) Check one that applies Level 1 - Near misses, preventative, and minor 1st aid injuries treated and released Level 2 - Significant injuries requiring emergency medical transportation and/or emergency room treatment short term. Level 3 - Over night In-patient hospitalization of injured party, long term hospitalization or Death Type of Incident (Choose all that apply) Nature of Injury/Illness No Injury/Illness Internal Chemical Exposure/Reaction Disease Bruising Foreign Body Electrical Shock Concussion Open Wound Inflammation Respiratory Loss of Concious Fracture Poison Cardiac/Circulatory Amputation Dislocation Loss of Senses Blood borne/Infection Exposure Death Threat Property Damage Policy Violation Other Body Part(s) Affected None Neck Hands/Wrists/Fingers Head Chest/Shoulders Hip/Pelvis Eyes Flank/Sides Legs Ears Back Knees/Feet/Toes Nose Abdoman Groin Mouth Arms Buttocks Other Possible Causes/Why did it happen? (Choose all the apply) Equipment Defective or Improper Tools/Equipment Poor Material No/Inadequate/Altered Safety Devices Improper Work Technique PPE Used Improperly/Not Used Failure to Warn/Secure Lack of Service/Maintenance Un-Safe Design/Construction Other Environment Inclement Weather Slippery/Uneven Surfaces Hazardous Substance Inadequate Ventilation Insufficient/Excessive Illumination Extreme Temperatures Air Contaminants Excessive Noise Congested Work Area Other Policies/Procedures Failure to Follow Procedure/Policies Lack of Procedures/Policies Insufficient Training/Knowledge Lack of Proper Supervision Management System Deficiencies Inadequate Inspections Unrealistic Scheduling Inadequate Planning/Preparedness No Support/Assistance Other Human Factors Failure to Follow Procedures/Guidelines Poor Performance Improper/No PPE Safety Rules Not Enforced Safety Violation Hazards Not Identified Lack of Maintenance Poor Housekeeping Improper Lifting Inattention/Rushing Un-Safe Act/Horseplay Violence Other
