NCH Corporation

Injury / Illness / Incident /Accident Report and Return to Work Form

ATTENTION : This form may contain information relating to an Associate’s work-related injury or illness and must be used in a manner that protects the confidentiality of the Associate to the maximum extent possible.

An Associate Accident Report must be completed and filed as soon as possible for every work-related accident or illness. Immediately following any accident the Associate must be drug tested even if no medical attention is required.

The injured Associate (if possible) and the immediate supervisor are responsible for gathering all of the requested information and reporting it to Corporate Human Resources by telephone, fax, email or overnight mail.

When medical treatment is required, the Return to Work portion must be completed by the treating Medical personnel and returned to the supervisor or HR before the Associate can return to work.

Below are guidelines for completing this form (please print neatly in ink).

Associate Responsibilities:

  • Promptly seek medical treatment if necessary (see “Medical Treatment” section below).
  • Immediately notify supervisor/designated person in charge of work-related accident or illness.
  • Fully complete “Associate Information” and “Accident Information” sections, sign, and date the report.
  • Give form to supervisor/designated person in charge for signature.

Supervisor Responsibilities:

  • Complete “Supervisor” section. Sign and date the report. Immediately following any accident Associate must be drug tested even if no medical attention is required. If Associate needs or desires medical treatment, arrange for appropriate medical care (see “Medical Treatment” section below). Be certain the Associate knows not to use their personal insurance for any medical charges. All treatment should be charged to Workers’ Compensation.
  • If Associate does not need or desire medical treatment, make a copy of this report for your records and send the original to Corporate Human Resources (address is listed below). Forward drug test results to Corporate HR as soon as possible. If medical treatment is needed at a later date as a result of this accident, refer Associate to Corporate Human Resources.

Medical Treatment

  • If the injury or illness requires medical attention, the Associate should be directed to receive medical treatment immediately. The Associate should not use their personal insurance for any medical charges. All treatment should be charged to Workers’ Compensation. Your Human Resources Representative or designated safety coordinator will provide additional information regarding preferred providers. Immediately following any accident Associate must be drug tested even if no medical attention is required.

For exposure to blood and body fluids:

Associates should report exposure to other people’s blood or bodily fluids even when they themselves are not injured or ill. Precautionary medical treatment may be required for protection against bloodborne pathogens.

Submit the Associate Accident report as soon as possible by telephone, fax, email or overnight mail to:

NCH Human Resources

2727 Chemsearch Blvd

Irving, Texas 75062

972-438-0227 (phone)

972-438-0707 (fax)

Submit the Return to Work Form before Associate returns to work by telephone, fax, email or overnight mail to:

NCH Human Resources

2727 Chemsearch Blvd

Irving, Texas 75062

972-438-0227 (phone)

972-438-0707 (fax)

Injury / Illness / Incident /Accident Report

Page 1 of 3

Section I: ASSOCIATE INFORMATION

Full Name: ______SSN: ______ORACLE number: ______

Home Street Address:______

City: ______State: ______Zip Code: ______

Sex: M FDate of Birth: ___/____/____Date Hired: ___/____/____

Home Phone #:______Alternate Phone #: ______

E-mail address: ______Hired out of which state: ______

Marital Status: ______Number of Dependents: ______

Company: ______Department: ______

Job Title: ______Full Time or Part Time

Work Phone # ______Work location: ______

Supervisor’s Name (printed):______Supervisor’s Phone #: ______

Supervisor’s e-mail address: ______Trained by: ______

Section II: ACCIDENT INFORMATION

Date of accident: ___/____/____ Time of accident: ______am / pm Time Shift Began: ______am / pm

Location of Accident (business name with full address, or street name, intersection, highway): ______

What job, activity or task was being done when the accident occurred? (Examples: loading/unloading containers from a transport vehicle: moving drums: driving on a highway: replacing a valve or pipe/tubing fitting: filling a pail with chemicals)

______

Explain in detail what happened(Ex: While bending over to pick up a wrench, the associate pulled a muscle in his/her back)______

______

What caused the injury? (Examples: name of chemical, falling object, sharp edge, improper lifting, etc)______

Was this part of normal job duty? Yes NoWas PPE required? Yes NoWas PPE used? Yes No

Explain all “No” answers: ______

Was PPE modified? Yes NoWas accident reported to Manager? Yes No If Yes, when? ______

Was Associate drug / alcohol tested? Yes No Did the Associate seek medical treatment? Yes No

If “YES”, date of initial visit and name and address of hospital/clinic and name of attending physician or health care provider)______

Was Associate taken by ambulance or helicopter? Yes No Was Associate Hospitalized? Yes No

Did doctor give a Return to Work note? Yes No If Yes, please provide copy

Are work restrictions required? Yes No If Yes, can the restrictions be accommodated? Yes No

2727 Chemsearch Blvd, Irving, Texas 75062 fax: 972-438-0707 972-438-0227

NCH Corporation

Injury / Illness / Incident /Accident Report

Page 2 of 3

Specific body part(s) affected or injured (Ex: Left Hand, Right Eye or Low Back): ______

Type of injury or illness (Ex: sprain, laceration, burn, etc.) ______

What object or substance directly harmed the Associate? (Ex: hammer, steering wheel, knife blade, saw blade, acid, hot oil, hot water) ______

CURRENT DISPOSITION / YES / NO
Lost Time Accident
Returned to Regular Job
Returned to Restricted Duty
First Aid Only
Sent to Panel Doctor or Clinic
Sent to Hospital
Went to Own Physician
History of Previous Accidents
DATE
Date Lost Time Began
Date Returned to Work

Witnesses (Name and Phone #) ______

Report prepared by (if different from the injured Associate):

Print Name: ______Phone #:______

Associate Signature: ______Date: ___/____/____

ADDITIONAL COMMENTS / NOTES

Injury / Illness / Incident /Accident Report

Page 3 of 3

ALL ACCIDENTS ARE THE RESULTS OF UNSAFE ACTS AND/OR UNSAFE CONDITIONS.

INVESTIGATE THOROUGHLY AND CHECK THE CAUSE OR CAUSES BELOW.

EACH UNSAFE ACTS AND UNSAFE CONDITIONS QUESTION MUST HAVE A “YES” OR “NO” ANSWER.

UNSAFE ACTS / YES / NO / UNSAFE CONDITIONS / YES / NO
Operating unguarded machine / Lack of training/Job procedure
Put hand in point of operation / Inadequately guarded machine
Failure to lock-out/Remove power source / Improper material storage/stacking
Crowded space/awkward position / Congestion, lack of space
Improper dress, jewelry, hair / Improper/worn tools equipment
No safety shoes, glasses or gloves / Unsafe design/construction
Overexertion, reaching, stretching / Unsafe floors, ramps, stairways
Horseplay, unsafe acts of others / Improper lighting/visibility poor
Use of improper tools / Materials/substances on floors
Unauthorized operation of machine/equipment / Lack or personal protective equipment
Other / Other
NOTE: THERE CAN BE NO BLANKS IN THIS COLUMN / NOTE: THERE CAN BE NO BLANKS IN THIS COLUMN
WHAT WAS DONE UNSAFELY? / WHAT UNSAFE CONDITION EXISTED?
WHY WAS IT DONE THAT WAY? / WHY DID THIS/THESE CONDITIONS EXIST?
HOW WILL WE CONTROL THIS UNSAFE ACT? / HOW WILL WE PREVENT/CORRECT THESE CONDITIONS?
ASSOCIATE STATEMENT
ASSOCIATE’S SIGNATURE______ / COMPLETION DATE ______
Who will be responsible for Control of Unsafe Acts?
Be specific. / Who will re responsible for Correction of Unsafe Conditions? Be specific.

Return to Work Form

Associate Information

Full Name: ______SSN: ______ORACLE number: ______

Items Below to be Completed by Health Care Provider

Medical Provider

Printed Name: ______Signature: ______

Treatment Date: ___/____/____Return to Work Date: ___/____/____Follow up Date: ___/____/____

Did this injury or illness result in?

 loss of consciousness restriction of work or lost time transfer to another job

 a work-related illness potential exposure to blood or body fluid fatality

 injuries requiring treatment beyond first aid (see back of form for OSHA’s definition of first aid)

Is this injury or illness work related?Yes No

Body part(s) affected: ______

Does the Associate require lost time or restricted duty? Yes No

Please specify the initial number of days off or restricted duty as well as the specific restrictions on activity: ______

Diagnosis/Assessment: ______

______

Is this a re-aggravation of previous injury? Yes No

If yes,date of initial injury if known: ______

After receiving medical treatment the Associate is required to submit this form before returning to normal or restricted duty. You may give the form to the Associate to return to their supervisor or you may submit it by email, fax or mail to:

NCH HR, 2727 Chemsearch Blvd., Irving, TX 75062

Fax- 972-438-0707

Telephone – 972-438-0227 or

If you have questions or wish to discuss this form, please call Janna Vallhonrat in Human Resources at 972-438-0227

Information for Designated Safety Coordinator

OSHA’s definition of "first aid" means the following:

1904.7(b)(5)(ii)(A)

Using a non-prescription medication at nonprescription strength (for medications available in both prescription and non-prescription form, a recommendation by a physician or other licensed health care professional to use a non-prescription medication at prescription strength is considered medical treatment for recordkeeping purposes);

1904.7(b)(5)(ii)(B)

Administering tetanus immunizations (other immunizations, such as Hepatitis B vaccine or rabies vaccine, are considered medical treatment);

1904.7(b)(5)(ii)(C)

Cleaning, flushing or soaking wounds on the surface of the skin;

1904.7(b)(5)(ii)(D)

Using wound coverings such as bandages, Band-Aids™, gauze pads, etc.; or using butterfly bandages or Steri-Strips™ (other wound closing devices such as sutures, staples, etc., are considered medical treatment);

1904.7(b)(5)(ii)(E)

Using hot or cold therapy;

1904.7(b)(5)(ii)(F)

Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc. (devices with rigid stays or other systems designed to immobilize parts of the body are considered medical treatment for recordkeeping purposes);

1904.7(b)(5)(ii)(G)

Using temporary immobilization devices while transporting an accident victim (e.g., splints, slings, neck collars, back boards, etc.).

1904.7(b)(5)(ii)(H)

Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister;

1904.7(b)(5)(ii)(I)

Using eye patches;

1904.7(b)(5)(ii)(J)

Removing foreign bodies from the eye using only irrigation or a cotton swab;

1904.7(b)(5)(ii)(K)

Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs or other simple means;

1904.7(b)(5)(ii)(L)

Using finger guards;

1904.7(b)(5)(ii)(M)

Using massages (physical therapy or chiropractic treatment are considered medical treatment for recordkeeping purposes); or

1904.7(b)(5)(ii)(N)

Drinking fluids for relief of heat stress.

2727 Chemsearch Blvd, Irving, Texas 75062 fax: 972-438-0707 972-438-0227