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1、INCIDENT TITLE事件标题INCIDENT TRACKING NUMBER事件跟踪号码GROUP集团DIVISION部门SUB DIVISION分部SITE WHERE INCIDENT OCCURRED事件发生地点AIR PRODUCTS PREMISES? (yes or no)IF NO, INDICATE THE EXACT ADDRESSAPCI工厂？(是或否)如果不是,请指明具体地址INCIDENT DATE事件日期INCIDENT TIME事件时间NAME OF INJURED/ILL EMPLOYEE受伤/生病雇员姓名AGE年龄JOB TITLE职务TIME IN J
2、OB FUNCTION现岗位工作时间WORKPLACE OF RECORD (IF DIFFERENT THAN SITE WHERE INCIDENT OCCURRED)可记录的工作地点(如果与事件发生地点不一样)GROUP(集团): DIVISION(部门): SUBDIVISION(分部): FACILITY(工厂): HOME ADDRESS家庭地址INCIDENT DESCRIPTION事件描述IMMEDIATE CORRECTIVE ACTION立即采取的改正措施.OVERNIGHT HOSPITALIZATION (YES OR NO)通宵住院治疗(是或否)NAME AND AD
3、DRESS OF PHYSICIAN医生姓名和地址NAME AND ADDRESS OF HOSPITAL OR CLINIC医院或门诊部的名称和地址INVESTIGATION START DATE调查开始日期PROCESS KNOWLEDGEABLE?对工艺有认识的?INVESTIGATION TEAM调查组COMPANY/DEPARTMENT公司/部门YES/NO是/否WITNESS NAME, ADDRESS, PHONE NUMBER证人姓名，地址，电话号码INVESTIGATION SUMMARY调查小结1.WAS EMPLOYEE DIAGNOSED WITH AN OCCUPAT
4、IONAL ILLNESS?雇员是否被诊断为职业病？(i.e. hearing loss, cumulative trauma or repetitive stress injuries, etc.)(如：失聪，劳损或反复性压力损伤，等)2.DID INJURED EMPLOYEE LOSE CONSCIOUSNESS?受伤雇员是否失去知觉？3.WAS PRESCRIPTION MEDICATION PRESCRIBED OR SUPPLIED BY PHYSICIAN FOR MORE THAN ONE DOSE APPLICATION? IF YES, IDENTIFY PRESCRIPT
5、ION/DURATION.医生开出/提供的治疗处方是否多于一剂？如果是，请说明处方剂量/持续时间。4.DID INJURY INVOLVE 2ND OR 3RD DEGREE BURNS, CUTTING AWAY DEAD SKIN, REMOVAL OF FOREIGN BODIES FROM THE EYE BY TWEEZERS OR SCRAPING, A POSITIVE X-RAY DIAGNOSIS OR REQUIRE SUTURES, BUTTERFLY BANDAGE, OR STERI-STRIP(S)?是否为2级或3级烧伤，切除坏死皮肤，用镊子从眼中取出其他物体或碎片
6、，确实经过X光诊断或需要缝合，使用蝴蝶绷带或消毒绷带？5.WERE HOT/COLD SOAKS OR COMPRESSES, WHIRLPOOL BATH THERAPY, HEAT THERAPY OR APPLICATION OF ANTISEPTIC REQUIRED DURING SECOND OR SUBSEQUENT VISIT TO MEDICAL PERSONNEL?是否热/冷浸泡或热敷？涡流浴治疗，热疗或当第二次或随后对伤者的探视中需要使用消毒剂？6.DID INJURY/ILLNESS CAUSE RESTRICTION OF WORK OR MOTION?受伤/疾病是否
7、导致工作或行动受到限制？7.WAS EMPLOYEE TRANSFERRED TO ANOTHER JOB BECAUSE OF INJURY/ILLNESS?是否因受伤/疾病该雇员转换到其他的工作？8.DID EMPLOYEE MISS HIS/HER NEXT OR SUBSEQUENT SCHEDULED WORKDAY DUE TO INJURY/ILLNESS?该雇员是否因受伤/疾病而使得他/她未能在下一个或随后的即定工作日上班？9.WAS INJURY/ILLNESS FATAL TO THE EMPLOYEE?受伤/疾病对该雇员是否是致命的？10.RECORDABILITY TY
8、PE (RECORDABLE INJURY, RECORDABLE ILLNESS, OR FIRST AID)可记录的类型(可记录的工伤事故，可记录的疾病，或急救)11.RECORDABILITY CATEGORY (MEDICAL TREATMENT, RESTRICTED DUTY, LOST TIME, OR FATALITY)可记录的范畴(医疗治疗，工作受限，失时工伤事故，或死亡)12.IF A LOST TIME INCIDENT, NUMBER OF COMPLETE WORK DAYS LOST (ESTIMATE)如果为失时工伤事故，完全不能工作的天数(预计)13.IF A
9、RESTRICTED DUTY INCIDENT, NUMBER OF RESTRICTED WORK DAYS (ESTIMATE)如果为工作受限事件，受限的工作天数(预计)14.DESCRIBE TREATMENT/THERAPY:处理/治疗描述:NOTE: If you answered yes to any of the first 9 questions, then the injury is probably recordable and must be recorded on the site OSHA 200 Log within 6 days, pending final d
10、etermination. If medical treatment was (or should have been) provided and a yes answer was not logged, then consult your safety professional for determination of recordability.备注：对于前9个问题，如果你对任意一条的回答为“是”的话，则该工伤很有可能为可记录的，并且在6天内必须记录在现场OSHA 200 Log中等候最终的决定。如果施行了(或必须进行)医疗治疗，且未被记录为“是”，则依照你对安全的专业知识来判定是否为可记
11、录的工伤事故。ANSWER YES OR NO TO THE FOLLOWING QUESTIONS REGARDING FACTORS THAT WERE DIRECTLY INVOLVED AT THE TIME OF THE ACCIDENT.在事故发生时，对下列与直接因素有关问题进行“是”或“否”的回答：1.WAS AIR PRODUCTS PRODUCT INVOLVED?与APCI产品有关吗？2.DID THE INJURED/ILL PERSON ASSUME A RISK PREVIOUSLY IDENTIFIED AS A HAZARD?伤者/病人是否在事故发生前已认为有危险
12、？3.WAS THE INJURED/ILL PERSON WEARING REQUIRED PROTECTIVE EQUIPMENT?伤者/病人是否已经穿戴防护设备？4.WAS THE INJURED/ILL PERSON ENGAGED IN HORSEPLAY/FIGHTING?伤者/病人是否参与了嬉戏/打闹？5.WAS THE INJURED/ILL PERSON PERFORMING UNAUTHORIZED WORK?伤者/病人是否未经批准进行作业？6.WAS THE INJURED/ILL PERSON RUSHED/IN HASTE, UNDER STRESS, OR DIST
13、RACTED?伤者/病人是否在匆忙中，在压力下，或是在心烦意乱中贸然行事？7.DID THE INJURED/ILL PERSON APPEAR TO BE UNDER THE INFLUENCE OF ALCOHOL/DRUGS?伤者/病人是否在酒后/服食毒品后进行作业？8.DID THE INJURED/ILL PERSON VIOLATE RULES/PERMITS/PRACTICES/REGULATIONS?伤者/病人是否违反了规章制度/操作条例？9.WAS THE INJURED/ILL PERSON A VICTIM OF ANOTHER WORKERS ACTIONS?伤者/病人是否为其他工人行为的受害者？10.WAS THE INJURED/ILL PERSON AN INNOCENT BYSTANDER?伤者/病人是否为无辜的旁观者？NAME AND TITLE OF SUPERVISOR主管姓名和职务WORK TELEPHONE NUMBER办公电话DATE OF REPORT报告日期SUPERVISOR APPROVAL主管审批DATE OF APPROVAL审批日期
