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Accidente

Plantilla de accidente

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Accidente preview

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Date of accident

Shift

Morning

Afternoon

Night

Mixed

Weather

Cloudy

Cold

Hot

Rain

Snow

Company / Department

Users

Medical treatment type

First aid

Medical treatment

Restricted work

Incapacitating accident

Fatality

Injury type

Abrasion / Scratch

Amputation

Foreign body

Unknown

Strain / Sprain

Fracture

Internal

Laceration / Cut

Bruise

Multiple

Other

Burn / Scald

Chemical reaction

Dislocation

Injured part of the body

Arms / Wrist

Head / Skull

Face / Eyes / Ears / Nose

Neck / Shoulder

Fingers / Hands

Back / Trunk

Genitals

Legs / Knee

Ankles / Feet / Toes

Property or material damaged

Pictures of damage (if applicable)

Description

Pictures of accident

Injured worker factors

Select the injured worker factors that apply

Low intellectual capacity

Inappropriate physical characteristics (height, weight)

Confusion

Anger

Demotivation

Hearing / visual impairment

Previous illness / injury

Stress

Lack of attention / concentration

Lack of communication

Lack of effort

Lack of experience / skill

Fatigue

Hypersensitivity or allergy to the environment

Inadequate risk perception

Fear

Concern / Distress

Haste / Impatience

Excess motivation

Overconfidence

Sadness

Work factors

Select the work factors that apply

Poor access control

Improper environment and process design

Lack of staff support

Lack of legal compliance

Lack of inspections / audits / supervision

Lack of investment in safety

Lack of leadership

Missing motivation scheme

Lack or poor training

Inadequate management of equipment / tools / materials

Inadequate risk communication and management

Inappropriate safety management

Insufficient / inadequate staff

Poor change management

Poor policies and standards

Unsafe acts

Select the unsafe acts that apply

Drive at excessive speed

Running in work area

Failure to block dangerous energies

Smoking in fire/explosion risk areas

Entering prohibited areas without authorization

Disable guards and/or protections

Starting high-risk work without permission or authorization

Not wearing PPE or using it in poor condition

Failure to respect safety signs

Not using pedestrian walkways

Failure to check equipment, material, or tool before use

Bypass established procedure or method

Operates equipment or vehicle without authorization

Other

Improper position for the task

Working under the influence of drugs or narcotics

Working in dirty / messy area

Use of improper or defective equipment / vehicle / tool

Improper use of equipment / vehicle / tool

Use of cell phone, headphones, cameras on site

Violate work rules or procedures

Unsafe conditions

Select the unsafe conditions that apply

Unprotected heights

Improper lockout of equipment, area, or process

Inadequate or faulty PPE

Inadequate or damaged structures, roads, trails

Lack of order and cleanliness

Inadequate or defective guards or safety devices

Improper or defective tool, equipment or vehicle

Inadequate distribution of the workplace

Inadequate or excessive lighting

Moving machinery or equipment

Improperly energized machinery or equipment

Objects at risk of falling

Other

Sharp or slippery parts / surfaces

Presence of harmful fumes, gases or dust

Presence of hazardous materials / chemicals

Radiation

Noise

Inadequate or faulty signs

Extreme temperatures

Inadequate ventilation

Vibrations

Zone vulnerable to fire or explosion

Corrective measures to implement

Assigned users

Reviewer

Due at

Priority

5

4

3

2

1

Signature of the company representative

Signature of the EHS representative

Location

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