事故调查报告Incident Investigation Report-20150204 - 副本.docVIP

Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness. Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness. 说明：发生事故后应立即填写该报告（该报告也适用于调查可能引起较大伤害或者疾病的轻伤和虚惊事故） Number编号：_________ This is a report of a该事故属于: □ Death死亡 □Lost Time 损失工时 □Dr. Visit Only厂外就医 □First Aid Only 急救护理 □Near Miss虚惊 Date of incident事故日期: This report is made by报告填写人为: □Employee员工 □Supervisor主管 □EHS □Other其他_________ Step 1: Injured employee complete this part for each injured employee 受伤人员（此项目每一位受伤人员一份） Name姓名: Sex性别: □Male男 □Female女 Age年龄: Department部门: Job title at time of incident受伤时的工作职位: Part of body affected: shade all that apply 受影响的部位（涂黑） Nature of injury受伤性质: most serious one主要的一项 □Abrasion, scrapes摩擦刮伤 □Amputation 截肢 □Broken bone 骨折 □Bruise 挫伤，青肿 □Burn heat 热灼伤 □Burn chemical 化学灼伤 □Concussion to the head 脑震荡 □Crushing Injury压伤 □Cut, laceration, puncture 割伤，切伤，刺穿伤 □Illness 疾病 □Sprain, strain扭伤，拉伤 □Damage to a body system: 身体系统损害 □Other其他 ___________ This employee works: □Regular full time 全职 □Regular part time兼职 □Temporary临时工 Months with this employer工作年限 Months doing this job此工种年限: Step 2: Describe the incident事故描述 Exact location of the incident事故准确地点: Exact time事故时间: What part of employee’s workday时间段? □Entering or leaving work上下班 □Doing normal work activities 日常作业 □During meal period就餐时 □During break休息时 □Working overtime 加班□Other__________ Names of witnesses if any 目击者（如果有）: Number of attachments附件编号 Written witness statements目击者笔录: Photographs图片: Maps / drawings图纸: What personal protective equipment was being used if any 佩戴了何种劳防用品 Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details. 详细描述事故经过。包括设备，零部件，物品，工具，材料和其他细节 Description continued on attached sheets: 下接附件： Step 3: Why did the incident happen? Unsafe workplace co