can you create an incident form for me?

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# Effective Workplace Inspections (cont.) ## Are there other types of reports that may be useful? (cont.) Ongoing inspections: Supervisors and workers should conduct ongoing inspections as part of their job responsibilities. Such inspections identify hazardous or unusual operating conditions as they occur during the course of work. A hazard report may be generated to either correct the issue immediately or to request further corrective action. Hazard Reports about unsafe working conditions and hazards may be submitted directly or anonymously by workers, and by the health and safety committee or representative. Reports may include corrective action recommendations from the committee. Incident and investigation reports include a detailed inspection of the work area where the incident occurred and a root cause analysis. Being aware of how and why an incident occurred can help inspectors to identify the same hazard elsewhere. Incident trends can help to prioritize specific hazards, for example, if there have been several slip-trip-fall incidents or musculoskeletal (MSD) injuries in recent months. Inspection compliance orders and tickets (fines) may be given by inspection officers from the jurisdictional health and safety regulator, fire department, electrical authority, and other regulatory bodies. Inspection may occur at any time, for a targeted blitz, or in response to a reportable incident, fatality, or complaint. These legal orders must be complied with and receive immediate priority. Pre-operation checks are performed by workers at the beginning of their shift, before they begin to use the machine, vehicle, equipment, or process. Daily checks by users assure that the equipment meets minimum acceptable safety requirements. The frequency of these inspections varies with the amount and conditions of equipment use. Several pre-operation checklists may be completed each day by different workers. These checks are also done after workplace shutdowns, provided no mod…

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# medical treatment was necessitated by the workplace event or exposure. (cont.) ## Section 350.340 Forms (cont.) 4) This form must be kept on file for 5 years following the year to which it pertains. The Incident Report Form has to be completed within 7 calendar days after notice of the injury or illness. These forms shall be maintained for at least 5 years. (Source: Amended at 46 Ill. Reg. 3518, effective February 15, 2022) - Section 350.350 Multiple Establishments a) Basic Requirement Keep a separate OSHA 300 Log for each establishment that is expected to be in operation for one year or longer. b) Implementation 1) Keep OSHA injury and illness records for short-term establishments (i.e., establishments that will exist for less than a year), but the employer does not have to keep a separate OSHA 300 Log for each such establishment. One OSHA 300 Log may be kept that covers all of the employees short-term establishments. Include the short-term establishments' recordable injuries and illnesses on an OSHA 300 Log that covers short-term establishments for individual company divisions or geographic regions. 2) Keep the records for an establishment at the employer's headquarters or other central location if the employer can: A) Transmit information about the injuries and illnesses from the establishment to the central location within 7 calendar days after receiving information that a recordable injury or illness has occurred; and B) Produce and send the records from the central location to the establishment within the time frames required by Sections 350.390 and 350.420 when the employer is required to provide records to a government representative, employees, former employees or employee representatives. 3) Each employee must be linked to one of the employer's establishments for recordkeeping purposes. Record the injury and illness on the OSHA 300 Log of the injured or ill employee's establishment or on an OSHA 300 Log that covers that employee'…

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# medical treatment was necessitated by the workplace event or exposure. (cont.) ## Section 350.340 Forms (cont.) d) Injury and Illness Incident Report - OSHA Form 301 1) In addition to the OSHA Form 300 of injuries and illnesses, each employer shall maintain in each workplace a supplementary record of each recordable occupational injury and illness for that workplace. The employer shall complete the incident report and make it available as early as practicable, but no later than 7 calendar days after receiving information that a recordable injury or illness has occurred. The OSHA Form 301, IWCC Form 45, or a suitable substitute that contains the same information as either of those two forms may be used as the supplementary record. Records shall be available to any agency requesting them pursuant to Section 60 of the Act. 2) The OSHA Form 301 (Injury and Illness Incident Report) shall contain the following information for each recordable injury and illness: A) Information about the employee: i) Full name and address. ii) [redacted identifier] date of hire. iii) Gender. B) - Information about the physician or other health care professional: i) Name of physician or health care professional. ii) Location where treatment was administered. iii) If an emergency room was visited or if the employee was hospitalized overnight as an in-patient. C) Information about the case: i) Case number corresponding to the Log of Injuries/Illnesses. ii) Date of Injury or Illness. iii) Time employee began work and time of event, if known. iv) What the employee was doing just before the incident occurred. v) What happened. vi) What was the injury or the illness. vii) What object or substance directly harmed the employee. viii) If the employee died, date of death. 3) The name and title of the individual who completed the form, along with the telephone number and the date of completion.

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# IMMINENT DANGER, FATALITY, CATASTROPHE, AND EMERGENCY RESPONSE (cont.) be a criminal offense. Making a false statement, upon conviction, is punishable by a fine of up to $10,000 or six months in jail, or both. E. Investigation Documentation. - Document all fatality and catastrophe investigations thoroughly. 1. Personal Data - Victim. Potential items to be documented include: Name; Address; Email Address; Telephone; Age; Sex; Nationality; Job Title; Date of Employment; Time in Position; Job being done at the time of the incident; Training for job being performed at the time of the incident; Employee deceased/injured; Nature of injury - fracture, amputation; and Prognosis of injured employee. 2. Incident Data. Potential items to be documented include: How and why the incident occured; the physical layout of the worksite; sketches/ drawings; measurements; video/audio/photos to identify sources; and whether the accident was work-related. 3. Equipment or Process Involved. Potential items to be documented include: Equipment type; Manufacturer; Model; Manufacturer's instructions; Kind of process; Condition; Misuse; Maintenance program; Equipment inspection (logs, reports); Warning devices (detectors); Tasks performed; How often equipment is used; Energy sources and disconnecting means identified; and Supervision or instruction provided to employees involved in the incident. 4. Witness Statements. Potential witnesses include: the Public; Fellow employees; Management; Emergency responders (e.g., police department, fire department); and Medical personnel (e.g., medical examiner). 5. Safety and Health Program. - Potential questions include: - Does the employer have a safety and/or health program? - Does the program address the type of hazard that resulted in the fatality/catastrophe? - How are the elements of the program specifically implemented at the worksite? 6. Multi-Employer Worksite. - Describe the contractual and in practice relations…

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# medical treatment was necessitated by the workplace event or exposure. (cont.) ## Section 350.340 Forms (cont.) must be designated at the top of the log. Within 7 calendar days after receiving information about a case, the employer shall: A) Decide if the case is recordable under the recordkeeping provisions of Section 350.220. B) Determine whether the incident is a new case or a recurrence of an existing one. C) Establish whether the case was work-related. E) Decide which form to fill out as the injury/illness incident report form required under Section 350.340(a), OSHA Form 301 (Injury and Illness Incident Report), IWCC Form 45, or a suitable substitute that contains the same information as either of those two forms. 2) The OSHA Form 300 shall contain the following information for each recordable injury and illness: A) A unique case number assigned by the employer to this specific illness or injury to facilitate comparisons with the supplementary record of the illness or injury; B) The name of the affected employee, unless protected as a privacy case due to the nature of the injury or illness; C) The job title of the employee; D) The date of the injury or onset of illness; E) Location where the event occurred; F) A description of the injury or illness, parts of the body affected, and object or substance that directly injured or made the person ill (e.g., second degree burns on right forearm from acetylene torch); G) The most serious result from each case: i) Death; ii) Days away from work; iii) Remained at work; job transfer or restriction (see federal form); iv) Remained at work; other recordable cases (see federal form); H) The designation of injury or the type of illness (e.g., skin disorder, respiratory condition, poisoning, hearing loss, all other illnesses); I) The number of days the injured or ill worker was either on job transfer or restriction or away from work. 3) The OSHA Form 300 and its su…

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# medical treatment was necessitated by the workplace event or exposure. (cont.) ## Section 350.375 Electronic Submission of OSHA Form 300A (cont.) Employees and their representatives must be involved in the recordkeeping system in several ways. 1) The employer must inform each employee of how to report an injury or illness to the employer. 2) The employer must provide limited access to its injury and illness records for its employees and their representatives. b) Implementation 1) The employer must establish a process for employees to report work-related injuries and illnesses promptly and must inform each employee regarding the process to report work-related injuries and illnesses. 2) The employer must give its employees and their representatives access to the OSHA injury and illness records. Employees, former employees, their personal representatives, and their authorized employee representatives have the right to access the injury and illness records, with the limitations provided in this subsection (b). 3) An authorized employee representative means an authorized collective bargaining agent of employees. 4) A personal representative is: A) Any person that the employee or former employee designates as such, in writing; or B) The legal representative of a deceased or legally incapacitated employee or former employee. 5) When an employee, former employee, personal representative, or authorized employee representative asks for copies of the current or stored OSHA Form 300 for an establishment the employee or former employee has worked in, the employer must give the requester a copy of the relevant OSHA Form 300s by the end of the next business day. 6) Privacy A) The employer shall not remove the names of the employees or any other information from the OSHA Form 300 before giving copies to an employee, former employee, personal representative, or employee representative. However, to protect the privacy of injured and ill employees, the em…