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Can you please help me create a form template that can be uploaded into Salus from a form that is attached

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To create a safety form template in Salus from an attached form, structure the template so it captures document control, required data fields, workflow approvals, and retention requirements while preserving all information needed for incident, hazard, inspection, and PPE/risk-assessment processes. If you are using an existing paper/PDF form as the source, convert each prompt, checkbox, signature, and date field into a discrete Salus field, and make mandatory any field needed for legal recordkeeping, corrective action tracking, or internal accountability. For recordable injury/illness forms, an equivalent electronic form must contain all instructions and information requested on the source form. [8] [14]

Recommended template sections and field requirements:

  • Document control: form title, unique form ID/number, revision number, effective date, review date, owner/department, approval status, and superseded-version control.
  • Compliance metadata: project/site/location, employer/company name, department, job title, supervisor, assessor/investigator/completed-by name, and dates/times of submission and event.
  • Incident reporting fields: employee name, incident date, time of incident, normal schedule/overtime status, day of week, exact location, whether it occurred on employer premises, action taken by company, detailed incident description, body part affected, type of incident, PPE in use, witnesses, medical treatment, workers' compensation status, whether employee left work, and supervisor comments.
  • Hazard reporting and risk assessment fields: task/step, identified hazard, who may be affected, consequences/harm, risk level, priority, hazard controls, additional notes, assessor signature, committee/representative signature, and completion date.
  • Inspection/PPE assessment fields: work area, job/task/equipment, exposure categories, whether hazards can be eliminated without PPE, selected PPE by body area, and verification that controls are implemented and understood by workers.
  • Corrective action and closure fields: unsafe condition identified, corrective action required, responsible person, target date, completion date, verification of effectiveness, and closeout approval.
  • Approval workflow: employee/worker signature where applicable, supervisor signature, completed-by/investigator signature, title, date, and management or safety approval for final closure.
  • Recordkeeping and confidentiality: confidentiality flag for employee health information, retention period, case/log number linkage, and restricted access permissions for medical or injury data.

[2] [3] [6] For document control in Salus, build the form so every uploaded template has a controlled lifecycle. At minimum, include the form name, revision number, effective date, review date, and approver. Lock obsolete versions from use, and require users to complete only the current approved version. This is especially important where the form supports regulatory reporting, because the electronic version must remain equivalent to the required source form and preserve all required prompts and instructions. [8] [16]

For incident reporting templates, include enough detail to support internal investigation and OSHA/MIOSHA/Cal/OSHA-style recordkeeping. Required fields should capture what the employee was doing before the event, what happened, the injury or illness, and the object or substance that directly harmed the employee. Also include case number linkage, treatment details, hospitalization/emergency room questions, and death information if applicable. Configure date/time fields and narrative fields separately so reports can be searched and trended in Salus. [8] [8] [8] [8]

Your incident template should also preserve the practical investigation elements shown in standard accident forms: witnesses, supervisor comments, prevention measures, whether unsafe conditions were corrected, and what still needs to be done if they were not corrected. These fields are critical for corrective action tracking and closure in Salus. [3] [3] [3]

For hazard reporting and risk assessment templates, use a structured table format in Salus that lets users document the step or task, hazard, consequences or harm, risk level, priority, and hazard controls. Include a risk-ranking method such as a matrix and require documentation of how decisions were reached. The form should support the hierarchy of controls and allow reassessment after controls are implemented. [5] [6] [13]

A strong Salus hazard form should mirror the risk assessment process: identify hazards, assess and rank risk, determine controls, implement controls, measure effectiveness, and improve continuously. Add fields for responsible person, due date, verification date, and effectiveness review so the form functions as both an assessment and a corrective-action tracker. [13] [13] [13]

For PPE hazard assessment or inspection templates, organize fields by body area and exposure type. Include work area/location, assessor, date, job/task, exposure sources, whether the hazard can be eliminated without PPE, and the selected PPE. This supports defensible PPE selection and makes the form easier to configure in Salus using conditional logic: if the user selects "No" for hazard elimination, then the PPE selection fields become required. [7] [7] [15]

Include detailed PPE options only where they support the work being assessed. Typical selectable fields include eye/face protection, hand protection, foot protection, respiratory protection, hearing protection, and body protection, with exposure prompts tied to the task. This makes the template usable for inspections and hazard assessments without forcing irrelevant fields on every user. [7] [11] [10] [12]

For approvals and signatures, configure Salus to capture electronic signatures, printed name, title/role, and date for each required approver. At minimum, include the person completing the form and the supervisor or employer representative; for investigations or assessments, also include assessor/investigator and committee or safety representative signoff where required by your process. [1] [3] [4]

For training/compliance acknowledgment fields, if the form is used to document worker understanding of hazards or controls, include employee acknowledgment, trainer name, training date, and topics covered. This is useful when the uploaded form is intended to support hazard communication, orientation, or control verification in Salus. [9] [9] [16]

For regulatory and recordkeeping requirements, configure the template and workflow so recordable injury/illness reports can be completed within 7 calendar days of learning of the case, retained for 5 years following the year to which they pertain, and protected for confidentiality because they contain employee health information. Add restricted permissions in Salus for medical details and case records, and include a field for the log case number so the form can be tied to the injury/illness log. [8] [8] [8]

Practical Salus build guidance:

  1. Map every field from the attached form into a Salus field type: text, date, time, dropdown, checkbox, signature, photo/sketch upload, or long narrative.
  2. Use conditional logic so follow-up questions appear only when triggered, such as medical treatment, workers' compensation filing, hazard not eliminated, corrective action incomplete, or hospitalization.
  3. Make legally significant fields mandatory: event date/time, employee/worker identity where applicable, location, description, injury/illness details, corrective actions, signatures, and dates.
  4. Use standardized dropdowns for incident type, body part, injury type, risk rating, and status to improve reporting and analytics.
  5. Add attachment capability for sketches, photos, witness statements, and supporting documents; this is especially useful where the source form includes an illustration area.
  6. Include workflow statuses such as Draft, Submitted, Under Review, Corrective Action Open, Closed, and Archived.
  7. Assign permissions by role so supervisors can review, safety can investigate and close, and sensitive medical details are restricted.
  8. Set retention and archive rules consistent with applicable injury/illness recordkeeping requirements and your internal document control procedure.

[1] [3] [2]

16 source record(s)

Sources used for this answer

[1] Incident Investigation Form

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# INCIDENT INVESTIGATION REPORT KEMI Making workers' comp work 1. Injured Employee Information Name Job Title Incident Date 2. Time of Incident OAM OPM 3. Was the incident during the employee's normal work schedule? Yes No ◎ Overtime O 4. Day of Week Mon Tues Wed O 5. Location Thurs Fri Sat◎THE SCHEDE ◎ Please describe the location where the incident occured: 6. Did incident occur on employers' premises? Yes No ◎ 7. Action Taken by Company In Plant First Aid Medical Treatment Lost Work Day 8. Provide an explanation of the incident. (Be specific) 9. Part of Body Affected Head Chest Eye Lungs Ear Abdomen Neck Groin Shoulder Hips Arm Knee Elbow Leg Wrist Ankle Hand Foot Finger Toes Back Other ## 10. Type of Incident Overexertion Fall - Different Level Fall Same Level Struck Against Caught Between Struck By Vehicle Electrical Extreme Temps Repetitive Motion Radiation Absorption Slip (no fall) Twist Other

[2] COR 2020 Observation Questions (PDF Form)

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# COR® 2020 Observation Questions (cont.) ## Observations (cont.) NATIONAL COR IHSA.ca Work Safe for Life IHSA COR® 2020 Observation Questions <table><tr><th>1.1.9</th><th>Is visibly posted in the workplace?</th><th>2</th><th>*</th><th>Interview or Observation</th></tr><tr><td>Workers</td><td>Where would you find the health and safety policy?</td><td></td><td></td><td></td></tr><tr><td>Auditor's Notes/Observation</td><td>Notes</td><td></td><td></td><td></td></tr><tr><td colspan="5"></td></tr></table> <table><tr><th>2.12</th><th>Are documented controls implemented for identified hazards?</th><th>3</th><th></th><th></th><th>Observation and Interview</th></tr><tr><td>Management</td><td>Do you feel that the hazard controls are working? Why or why not?</td><td></td><td></td><td></td><td></td></tr><tr><td>Workers</td><td>Do you feel that the hazard controls are working? Why or why not?</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="2">Auditor's Notes/Observation Notes</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6"></td></tr></table> 3.4 Do the documented controls accurately reflect the organization's activities? Auditor's Notes/Observation Notes 3 2 Documentation and Observation <table><tr><th>3.7</th><th>Are the controls understood by workers?</th><th>2</th><th></th><th></th><th>Observation and Interview</th></tr><tr><td>Management</td><td>How do you determine that workers understand the controls?</td><td></td><td></td><td></td><td></td></tr><tr><td>Workers</td><td>Do you find the controls easy to understand? Give me two examples of controls.</td><td></td><td></td><td></td><td></td></tr></table> Infrastructure Health & Safety Association (IHSA) © 12/20 3

[3] Cal/OSHA Form 301 - Injury and Illness Incident Report

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# Cal/OSHA Form 301 Appendix C Injury and Illness Incident Report Attention:This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. See CCR Title 8 [redacted postal code].29(b)(6)-(10) CAL OSHA Department of Industrial Relations Division of Occupational Safety & Health This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable work- related injury or illness has occurred. Together with Log of Work-Related Injuries and Illnesses and the accompanying Annual Summary, these forms help the employer and Cal/OSHA develop a picture of the extent and severity of work-related incidents. Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers' compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the instructions and information asked for on this form. Information about the employee ## Information about the case According to CCR Title 8 Section [redacted postal code].33 Cal/OSHA's recordkeeping rule, you must keep this form on file for 5 years following the year to which it pertains. Completed by Title 10) Case number from the Log (Transfer the case number from the Log after you record the case.) 1) Full name Date 2) Street City State ZIP 3) Date of birth 4) Date hired 5) Male Female Information about the physician or other health care professional If you need additional copies of this form, you may photocopy and use as many as you need. 6) Name of physician or other health care professional 7) If treatment was given away from the worksite, where was it given? Facility Street City State ZIP 8) Was employee treated in an…

[4] Hazard and Risk - Sample Risk Assessment Form

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# What is a sample risk assessment form? The following is a sample. Be sure to customize it for your needs at your workplace. How you actually assess the risks can vary from situation to situation, and may include the technique of brainstorming, or using a checklist or a risk matrix. Document the process used, and how decisions were reached. ## Sample Risk Assessment Form Name of person(s) doing assessment: Date: Location: Job, activity, task or procedure being assessed: Hazards, Risks, and Controls: List details about each identified hazard below, including the step or task they are associated with, what they are and who they may impact, what the potential consequences are if workers are exposed to the hazard, the level risk (e.g., can use risk matrix below), the priority (hazards with the highest risk should be the top priority to address), and what are the recommended hazard controls to eliminate or reduce the risk. Hazard and Risk - Sample Risk Assessment Form CCOHS

[5] PPE Hazard Assessment Certification Form

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# PPE Hazard Assessment Certification Form (cont.) MAINE DEPARTMENT OF LABOR S Safety Works! MAINE DEPARTMENT OF LABOR [ ] PAPR (Air recycle) [ ] PPSA (Air supply) half faced full faced hooded ## EARS/HEARING Work activities such as: [ ] generator [ ] ventilation fans [ ] motors [ ] sanding [ ] pneumatic equipment [ ] other: Work-related exposure to: [ ] grinding [ ] machining [ ] routers [ ] sawing [ ] sparks Can hazard be eliminated without the use of PPE?: Yes [ ] No [ ] If no, use: [ ] ear muffs [ ] ear plugs SafetyWorks! Maine Department of Labor 1-877-SAFE-345 [redacted email]

[6] Hazard and Risk - Sample Risk Assessment Form

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CCOHS CCHST Canadian Centre for Occupational Health and Safety Centre canadien d'hygiène et de sécurité au travail Hazard and Risk # Hazard and Risk - Sample Risk Assessment Form On this page How can risks be assessed? What is a sample risk assessment form? Is there a procedure for assessing risks? ## How can risks be assessed? After hazards are identified, the risks associated with those hazards should be systematically reviewed to ensure those things, activities, situations, processes, tasks, etc. that cause harm to people or property are controlled. One way to ensure that all risks are evaluated in the same way is to use a risk assessment form. This procedure should be carried out by someone who is experienced and fully familiar with the activity (e.g., a "competent person"). Please note: see the OSH Answers Risk Assessment for more information about risk assessments in general, and how to rank hazards. ## Is there a procedure for assessing risks? There is no one way to assess risks, and there are many risk assessment tools and techniques that can be used. Choose the method that best matches your situation. In all cases, the risk assessment should be completed for any activity, task, etc. before the activity begins. <table><tr><th>Step</th><th>Action</th><th>Deliverable</th></tr><tr><td>1</td><td>Identify hazards and their potential for causing harm.</td><td>An inventory of hazards.</td></tr><tr><td>2</td><td>Assess the risk of each hazard and rank hazards by priority (consider the probability of harm and severity of harm).</td><td>A ranked list of hazards. This list will be useful in planning further action.</td></tr><tr><td>3</td><td>Determine hazard control measures.</td><td>1. A record of hazard control measures at various locations. 2. Evaluation of the adequacy of hazard control measures. Consider the hierarchy of controls, and controls required or recommended by legislation, standards, good practices, or organizational policies.</td></tr><tr><…

[7] PPE Hazard Assessment Certification Form

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# PPE Hazard Assessment Certification Form Laboratory location: Assessment conducted by: Investigator: - Date of assessment: Work area(s): Job/Task(s): (Use a separate sheet for each job/task or work area) ## EYES Work activities, such as: [ ] abrasive blasting [ ] sanding [ ] chopping [ ] cutting [ ] drilling [ ] chipping [ ] computer work [ ] other: <empty> Work-related exposure to: [ ] airborne dust [ ] dirt [ ] UV [ ] flying particles/objects [ ] blood splashes [ ] hazardous liquid chemicals mists [ ] chemical splashes [ ] glare/high intensity lights [ ] laser operations [ ] intense light [ ] hot sparks [ ] other: <empty> Can hazard be eliminated without the use of PPE? Yes [ ] No [ ] If no, use: With: [ ] Safety glasses [ ] Side shields [ ] Safety goggles [ ] Face shield [ ] Dust-tight goggles [ ] Shaded [ ] Impact goggles [ ] Prescription [ ] Chemical goggles [ ] Chemical splash goggles [ ] Laser goggles [ ] Shading/Filter (#_____) [ ] Welding shield [ ] Other: <empty> FACE Work activities, such as: [ ] cleaning [ ] siphoning [ ] painting [ ] mixing [ ] pouring [ ] other: <empty> Work-related exposure to: [ ] hazardous liquid chemicals [ ] extreme heat [ ] extreme cold [ ] potential irritants: [ ] other: <empty> Can hazard be eliminated without the use of PPE? Yes [ ] No [ ] If no, use: [ ] Face shield [ ] Shading/Filter (#_____) [ ] Welding shield [ ] Other: <empty> HANDS/ARMS Work activities, such as: [ ] material handling [ ] sanding Work-related exposure to: [ ] blood [ ] irritating chemicals Can hazard be eliminated without the use of PPE? Yes [ ] No [ ]

[8] Hazard and Risk - Sample Risk Assessment Form

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# What is a sample risk assessment form? (cont.) ## Sample Risk Assessment Form (cont.) Additional Notes: Signature of health and safety committee or representative: Signature of assessor(s): Date completed: Hazard and Risk - Sample Risk Assessment Form CCOHS

[9] Hazard-communication-training Form

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# Example of a hazard-communication-training form Use a form such as this one to document that an employee has been trained about hazardous chemicals used in the workplace as required by Oregon OSHA hazard-communication rules. I have been informed about the hazardous chemicals that I may be exposed to during my work and I have received training on the following topics: - An overview of the requirements in Oregon OSHA's hazard communication rules. - Hazardous chemicals present in the workplace. • The written hazard-communication plan. • Physical and health effects of the hazardous chemicals. - Methods to determine the presence or release of hazardous chemicals in the work area. • How to reduce or prevent exposure to these hazardous chemicals through use of exposure controls/work practices and personal protective equipment. - Steps we have taken to reduce or prevent exposure to these chemicals. - Emergency procedures to follow if exposed to these chemicals. - How to read labels and review safety data sheets. Note to employee: This form becomes part of your personnel file; read and understand it before signing. Employee: Date: Trainer: Date:

[10] Hazard and Risk - Sample Risk Assessment Form

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# What is a sample risk assessment form? (cont.) ## Sample Risk Assessment Form (cont.) <table><tr><th>Step or task</th><th>Hazard</th><th>Consequences or harm</th><th>Risk</th><th>Priority</th><th>Hazard Controls</th></tr><tr><td>EXAMPLE: Working at heights while on a ladder</td><td>Safety hazard: falling from heights</td><td>Serious injury due to a fall</td><td>High risk</td><td>1</td><td>Follow the hierarchy of controls for working at heights Elimination: when possible, perform work from the ground. Engineering controls: use an elevating work platform when appropriate. Administrative controls:</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td>development of fall protection plans, safe work procedures, emergency response plans for working at heights, and adequate training (including working heights and fall protection training, elevating work platform training, ladder safety, training on safe work procedures and emergency response, etc.). Personal protective equipment: fall arrest system and equipment, head protection, high-visibility. clothing, protective footwear, face and eye protection, emergency response equipment, and other appropriate equipment for the job.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr></table> Hazard and Risk - Sample Risk Assessment Form CCOHS

[11] PPE Hazard Assessment Certification Form

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# PPE Hazard Assessment Certification Form (cont.) MAINE DEPARTMENT OF LABOR S Safety Works! MAINE DEPARTMENT OF LABOR Work activities, such as: [ ] material handling [ ] grinding [ ] sawing [ ] hammering [ ] working with glass [ ] using power tools [ ] sanding Work-related exposure to: [ ] blood [ ] irritating chemicals [ ] tools or materials that could scrape, bruise, or cut [ ] extreme heat [ ] extreme cold [ ] animal bites [ ] electric shock [ ] vibration [ ] musculoskeletal disorders [ ] sharps injury [ ] other: <empty> Can hazard be eliminated without the use of PPE?: Yes [ ] No [ ] If no, use: [ ] Gloves [ ] Chemical resistance [ ] Liquid/leak resistance [ ] Temperature resistance [ ] Abrasion/cut resistance [ ] Slip resistance [ ] Latex or nitrile [ ] Anti-vibration [ ] Protective sleeves [ ] Ergonomic equipment: <empty> [ ] Other: <empty> FEET/LEGGS Work activities, such as: [ ] use of corrosive or flammable materials [ ] other: <empty> Work-related exposure to: [ ] explosive atmospheres [ ] explosives [ ] crushing [ ] sharps injury [ ] blood [ ] chemical splash [ ] chemical penetration [ ] extreme heat/cold [ ] other: <empty> Can hazard be eliminated without the use of PPE?: Yes [ ] No [ ] If no, use: [ ] Safety shoes or boots [ ] Toe protection [ ] Metatarsal protection [ ] Electrical protection [ ] Puncture resistance [ ] Anti-slip soles [ ] Heat/cold protection [ ] Chemical resistance SafetyWorks! Maine Department of Labor 1-877-SAFE-345 [redacted email]

[12] MIOSHA Form 301 - Injury and Illness Incident Report

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MICHIGAN DEPARTMENT OF LABOR & ECONOMIC OPPORTUNITY # INJURY AND ILLNESS INCIDENT REPORT ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. # Michigan Department of Labor and Economic Opportunity Michigan Occupational Safety and Health Administration (MIOSHA) Form Approved OMB No. 1218-0176 This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable work- related injury or illness has occurred. Together with the Log of Work-Related injuries and Illnesses and the accompanying Summary, these forms help the employer and MIOSHA develop a picture of the extent and severity of work-related incidents. Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers' compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the information asked for on this form. According to Public Law of 1970 (P.L. 91-596) and Michigan Occupational Safety and Health Act 154, P.A. 174, Part 11, Michigan Administrative Rule for Recording and Reporting Of Injuries and Illnesses, you must keep this form on file for 5 years following the year to which it pertains. You may be fined for failure to comply. If you need additional copies of this form, you may photocopy and use as many as you need Completed by Title Phone Date ## Information about the employee 1) Full Name 2) Street City State Zip 3) Date of birth 4) Date hired 5) Male Female Information about the physician or other health care professional 6) Name of physician or other health care professional 7) If treatment was given away from the worksite, where was it given? Facility Str…

[13] Incident Investigation Form

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# INCIDENT INVESTIGATION REPORT (cont.) ## 11. Did the employee report any of the following? Back Strain Sprain Dislocation Fracture Contusion Amputation Open Wound Burn Asphyixia Hearing Loss Foreign Body Multiple Injury Cumulative Trauma Other 12. After printing, use this area to illustrate the incident. (if applicable) 13. Personal Protective Equipment (PPE) in use at the time of the incident. 14. Note any additional information or recom- mendations. Employee: <empty> (Signature) Date: <empty> Completed by: <empty> (Signature) Title: <empty> Date: <empty>

[14] PPE Hazard Assessment Certification Form

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# PPE Hazard Assessment Certification Form (cont.) MAINE DEPARTMENT OF LABOR S Safety Works! MAINE DEPARTMENT OF LABOR Work activities such as: [ ] use of corrosive or flammable chemicals [ ] other: Work-related exposure to: [ ] chemical splashes [ ] extreme heat [ ] extreme cold [ ] sharp or rough edges [ ] irritating chemicals [ ] other: Can hazard be eliminated without the use of PPE?: Yes [ ] No [ ] If no, use: [ ] Vest, Jacket [ ] Flame resistant jacket/pants [ ] Coveralls, Body suit [ ] Raingear [ ] Apron [ ] Abrasion/cut resistance [ ] Other: <empty> With: [ ] Long or full sleeves [ ] Hood LUNGS/RESPIRATORY Work activities such as: [ ] cleaning [ ] mixing [ ] compressed air or gas operations [ ] confined space work [ ] other: Work-related exposure to: [ ] dust or particulate [ ] toxic gas/vapor [ ] chemical irritants (acids) [ ] pesticides [ ] organic vapors [ ] oxygen deficient environment [ ] extreme heat/cold [ ] other: Can hazard be eliminated without the use of PPE?: Yes [ ] No [ ] If no, use: [ ] Dust mask [ ] Disposable particulate respirator [ ] Replaceable filter particulate w/cartridge [ ] other: With/Type: [ ] face shield [ ] acid/gas crtdg [ ] organic crtdg [ ] pesticide crtdg [ ] spray paint SafetyWorks! Maine Department of Labor 1-877-SAFE-345 [redacted email]

[15] PPE Hazard Assessment Certification Form

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MAINE DEPARTMENT OF LABOR S Safety Works! MAINE DEPARTMENT OF LABOR # PPE Hazard Assessment Certification Form Location: <empty> Assessment conducted by: <empty> Job Title: <empty> Date of assessment: <empty> Job Task or Equipment: <empty> (Use a separate sheet for each job/task or work area) EYES Work activities, such as: [ ] abrasive blasting sanding [ ] chopping cutting drilling chipping computer work other: <empty> Work-related exposure to: [ ] airborne dust [ ] dirt [ ] UV [ ] flying particles/objects [ ] blood splashes [ ] hazardous liquid chemicals mists [ ] chemical splashes [ ] glare/high intensity lights [ ] laser operations [ ] intense light [ ] hot sparks [ ] other: <empty> Can hazard be eliminated without the use of PPE?: Yes [ ] No [ ] If no, use: With: [ ] Safety glasses [ ] Side shields [ ] Safety goggles [ ] Face shield [ ] Shaded [ ] Impact goggles [ ] Prescription [ ] Chemical goggles [ ] Chemical splash goggles [ ] Laser goggles [ ] Shading/Filter (#_____) [ ] Welding shield [ ] Other: <empty> FACE Work activities, such as: [ ] cleaning [ ] siphoning [ ] painting Work-related exposure to: [ ] hazardous liquid chemicals [ ] extreme heat [ ] extreme cold [ ] potential irritants: [ ] other: <empty> Can hazard be eliminated without the use of PPE?: Yes [ ] No [ ] If no, use: [ ] Face shield [ ] Shading/Filter (#_____) [ ] Welding shield SafetyWorks! Maine Department of Labor 1-877-SAFE-345 [redacted email]

[16] Accident or incident description form

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# Accident description form Use this form to document information about an accident or incident. Fill out an investigation report as soon as possible. Note: this form is for use within your company. It is not intended to replace DCBS Form 801: Worker's and Employer's Report of Occupational Injury or Disease. Employee(s) name(s): <empty> Time & date of accident/incident: <empty> Job title(s) and department(s): <empty> Supervisor or lead person: <empty> Witnesses: <empty> Brief description of the accident or incident: <empty> Body part affected: <empty> Did the injured employee(s) see a doctor?: [ ] Yes [ ] No If yes, did you file an employer's portion of a worker's compensation form? [ ] Yes [ ] No Did the injured employee(s) go home during their work shift? [ ] Yes [ ] No If yes, list the date and time injured employee(s) left job(s): <empty> Supervisor's Comments: <empty> What could have been done to prevent this accident/incident?: <empty> Have the unsafe conditions been corrected? [ ] Yes [ ] No If yes, what has been done?: <empty> If no, what needs to be done?: <empty> Employer or Supervisor's signature: <empty> Date: <empty> Additional comments/notes: <empty>

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