Incident Reporting and Investigation

Practice 000.653.1202

Date 01Apr2012

Attachment 01  Page 1 of 3

incident reporting and investigation

RECORDKEEPING CLASSIFICATION PROCESS

Is the case listed on the MIER as a recordable, DART-R, or DART-L? Yes No

Project Name: ______

Person Completing Form: ______

Name / Case No. / DOI
Yes / No
1.a / Is the case work-related? (If “no,” attach an explanation, and skip to the
“Classification” section; the case is not recordable.)
1.b / Does the case meet the definition of an injury or illness? (If “no,” attach an explanation, and skip to the
“Classification” section; the case is not recordable.)
1.c / Is the case exempted under one of the following? (check all that apply.)
Member of general public / Self-grooming/self-medicating/self-inflicting
Result solely from nonwork-related incident / MVA during commute
Voluntary participation / Common cold/flu
Result solely from preparing/eating / Mental illness
Performing personal task(s)
If “yes” to any of the exemptions above, skip to the “Classification” section; the case is not recordable.
2.a / Is this a new case?
2.b / Does this case involve a significant aggravation of a pre-existing condition?
(If “no” to both 2a and 2b, attach an explanation and skip to the “Classification” section;
the case is not a new recordable [update the previously recorded case information, if applicable]).
3. / Did any of the following occur? (An X in the “yes” box dictates that the case is recordable.
Check all that apply.)
Loss of consciousness / Transfer to another job / Restricted work
Days away from work/lost time / Death
4. / Was medical treatment provided? (An X in the “yes” box dictates that the case is recordable.)
Note: If the treatment provided is not on the First-Aid List on page 3, then “medical treatment” was provided
CLASSIFICATION: Injury Skin disorder Respiratory Poisoning
CTD Needle stick Hearing loss Report Only
Recordable / Yes / No
Restricted work activity case / Yes / No
Days away from work case / Yes / No
Documents reviewed to classify / Calendar WR/LT / OSHA 301 Form
Onsite Treatment Record / Incident Report / W/C Form
Offsite Treatment Record / Other
Description of injury/treatment (use reverse side if necessary)
Extenuating circumstances (use reverse side if necessary)
Interviews conducted with / Foreman / Employee / Superintendent / Manager / Other
Initial classification recommendation performed by: / Classification performed by:
Date / Date
Is this a change from a previous classification? / Yes (explain below) / No

FIRST-AID LIST

1904.7 (b)(5)(ii) What is “first aid”? For the purposes of OSHA, Part 1904, “first aid” means the following:

(iii) Are any other procedures included in first aid? No, this is a complete list of all treatments considered first aid for OSHA, Part 1904 purposes.

Health, Safety, and Environmental