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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