Injury Incident Form


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How to draft a Injury Incident Form? An easy way to start completing your document is to download this Injury Incident Form template now!

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Instead, we provide this standardized Injury Incident Form template with text and formatting as a starting point to help professionalize the way you are working. Our private, business and legal document templates are regularly screened by professionals. If time or quality is of the essence, this ready-made template can help you to save time and to focus on the topics that really matter!

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bone exposed) Closed fracture Dislocation Sprain, torn ligaments          Suffocation, asphyxiation Gassing Drowning Poisoning Infection Burns, scalds and frostbite Effects of radiation Electrical injury Property damage, Specify  Other, Specify Indicate part of body most seriously injured (put an ‘x’ in one box only):  Head, except eyes  Fingers, one or more  Eyes  Hip joint, thigh, knee cap  Neck  Knee joint, lower leg, ankle  Back, spine  Foot  Chest  Toes, one or more  Abdomen  Extensive parts of the body  Shoulder, upper arm, elbow  Multiple injuries  Lower arm, wrist, hand  Other, Specify Consequences of the Accident/Incident: Anticipated absence if not Date of resumption of work back Fatal  if back 4-7 days  Non Fatal  Year Month Day 8-14 days  More than 14 days  xv Treatment: xvi Doctor’s report and recommendation: xvii Steps taken to prevent reoccurrence of this type of Accident/Incident: Signature of person completing report: Date: Print Name Job Title: Signature of Head of Department/School/Function: Date: Print name: (Copies of the completed Institute Accident Report are to be sent separately to the Institute Health Safety Co-ordinator, the Vice President for Finance Corporate Affairs and the Estates Office).


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