BODY PART: Was there a safety procedure or mechanism available Yes No Was it in use at the time of incident Yes No Is the activity part of the normal job duties Yes No List names of anyone present at time of incident: Probable cause of incident (object or substance responsible for injury/illness): If indicated, what was discussed with employee to prevent recurrence Date: Supervisor Name: Extension: Employee’s Signature Beeper: Supervisor’s Signature Note: Any additional comments you feel are pertinent to an investigation of this incident can be made on a supplemental sheet and attached.. For Occupational Injury Clinic Use Only Inc Body Part Code: Disposition Full Duty Restricted Duty Referral (ER, WER, Ortho, Plastics, Etc) Recordable Yes Safety investigation requested No ICD9 DX Code Off Duty Restrictions not Accommodated RTC Scheduled RTC PRN as defined by OSHA Yes No If yes, comments: Healthcare Provider’s Signature/Title: Date JHH Form 15-1402020 5HY.
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