事故报告表格格式.doc

( INCIDENT TITLE 事件标题 INCIDENT TRACKING NUMBER 事件跟踪号码 ( GROUP集团 DIVISION部门 SUB DIVISION分部 ( SITE WHERE INCIDENT OCCURRED事件发生地点 AIR PRODUCTS PREMISES? (yes or no)IF NO, INDICATE THE EXACT ADDRESSAPCI工厂？(是或否) 如果不是,请指明具体地址 ( INCIDENT DATE事件日期 INCIDENT TIME事件时间 ( NAME OF INJURED/ILL EMPLOYEE受伤/生病雇员姓名 AGE年龄 JOB TITLE职务 TIME IN JOB FUNCTION现岗位工作时间 WORKPLACE OF RECORD (IF DIFFERENT THAN SITE WHERE INCIDENT OCCURRED)可记录的工作地点(如果与事件发生地点不一样) GROUP(集团): DIVISION(部门): SUBDIVISION(分部): FACILITY(工厂): HOME ADDRESS家庭地址 ( INCIDENT DESCRIPTION事件描述 ( IMMEDIATE CORRECTIVE ACTION立即采取的改正措施. ( OVERNIGHT HOSPITALIZATION (YES OR NO)通宵住院治疗(是或否) ( NAME AND ADDRESS OF PHYSICIAN医生姓名和地址 NAME AND ADDRESS OF HOSPITAL OR CLINIC医院或门诊部的名称和地址 ( INVESTIGATION START DATE调查开始日期 PROCESS KNOWLEDGEABLE? 对工艺有认识的? ( INVESTIGATION TEAM 调查组 COMPANY/DEPARTMENT公司/部门 YES/NO是/否 ( WITNESS NAME, ADDRESS, PHONE NUMBER证人姓名，地址，电话号码 ( INVESTIGATION SUMMARY调查小结 1. WAS EMPLOYEE DIAGNOSED WITH AN OCCUPATIONAL ILLNESS? 雇员是否被诊断为职业病？(i.e. hearing loss, cumulative trauma or repetitive stress injuries, etc.) (如：失聪，劳损或反复性压力损伤，等) 2. DID INJURED EMPLOYEE LOSE CONSCIOUSNESS? 受伤雇员是否失去知觉？ 3. WAS PRESCRIPTION MEDICATION PRESCRIBED OR SUPPLIED BY PHYSICIAN FOR MORE THAN ONE DOSE APPLICATION? IF YES, IDENTIFY PRESCRIPTION/DURATION. 医生开出/提供的治疗处方是否多于一剂？如果是，请说明处方剂量/持续时间。 4. DID INJURY INVOLVE 2ND OR 3RD DEGREE BURNS, CUTTING AWAY DEAD SKIN, REMOVAL OF FOREIGN BODIES FROM THE EYE BY TWEEZERS OR SCRAPING, A POSITIVE X-RAY DIAGNOSIS OR REQUIRE SUTURES, BUTTERFLY BANDAGE, OR STERI-STRIP(S)? 是否为2级或3级烧伤，切除坏死皮肤，用镊子从眼中取出其他物体或碎片，确实经过X光诊断或需要缝合，使用蝴蝶绷带或消毒绷带？ 5. WERE HOT/COLD SOAKS OR COMPRESSES, WHIRLPOOL BATH THERAPY, HEAT THERAPY OR APPLICATION OF ANTISEPTIC REQUIRED DURING SECOND OR SUBSEQUENT VISIT TO MEDICAL PERSONNEL? 是否热/冷浸泡或热敷？涡流浴治疗，热疗或当第二次或随后对伤者的探视中需要使用消毒剂？ 6. DID INJURY/ILLNESS CAUSE RESTRICTION OF WORK OR MOTION? 受伤/疾病是否导致工作或行动受到限制？ 7. WAS EMPLOYEE TRANSFERRED TO ANOTHER JOB BEC