汽车饰件企业管理之CIQF07-011工伤事故调查报告.doc

版次：A 实施日期： CIQF07-011工伤事故调查报告 Industries Accident/Incident Investigation Report编号： 日期： SECTION 1 SECTION 1-7 TO BE COMPLETED BY TEAM LEADER/DESIGNATE1. 健康、环境和安全制度Health、Environment and Safety Policy1至7部分由部门领导填写Please Print 请打印1.Employee Name Employee# Dept. 员工姓名：_ 工号：_ 部门：_ Date of Time & ShiftEmployees Job Incident of Incident 员工岗位：_ 事故发生日期：_ 事故发生时间及班次：_ _Date Team Leader/SupervisorSupervisors Name was Notified 上司姓名：_ 通报小组领导/主管日期：_ Did Incident Happen on the was the Employee PerformingEmployees Premises YES NO His/Her Normal Duties ? YES NO事故是否发生在雇佣方面前？ 是 否 员工是否正在执行其正常职责？ 是 否SECTION 22.Describe the events leading up to and including the incident：描述发生事故的起因及事故前后情况：_ Is this a Reoccurrence? If yes,please describe： 该事故是否再次发生？如是，请描述： YES（是） NO（否） _Was first aid provided? If yes, please write the name of the first aider是否对伤者进行急救？如有，请给出实施急救的人员姓名： YES（是） NO（否） _ _Did anyone witness this incident? If yes, list name: 是否有人目击该事故发生？如有，请列出姓名： YES（是） NO（否） _ SECTION 3 3.Main Body Part Injured (please check if no injury and go directly to SECTION 5)受伤部位 （请检查，如无受伤，至第5部份）Abdomen Eye L/R Hand L/R Respiratory腹部 眼睛 L/R 手 左/右 呼吸器官Ankle L/R Face Head Shoulder L/R脚踝 左/右 面部 头部 肩膀Back Upper /Lower Finger L/R Neck Teeth背部 上/下 手指 颈部 牙齿Buttocks L/R Foot-Toe L/R Hip L/R Upper Arm L/R臀部 左/右 脚趾 左/右 腰部 左/右 上臀 左/右Chest Forearm L/R Knee L/R Wrist L/R胸 前臀 左/右 膝盖 手腕 左/右Elbow L/R Groin Leg L/R Other 手肘 腹股沟 腿 其它_ Multiple Areas if None Predominant 多处受伤，如无主要受伤部位SECTION 4 Natuer of the Injury SECTION 5 Type of Incident/Accident4.受伤性质 5.事故类型Scratch/Abrasion Insect Bite Property Damage/Loss/Misuse擦伤 虫子叮咬 财务损坏/丢失/误用Amputation Laceration /Cut Struck Against(bump into running into)切断 割伤Infection/Rash Puncture Wound Struck By Object(hit or moving object)传染感染 刺伤 Burn Sliver Fall to Lower Level(stairs,ladder,heights)烧伤Bruise/Contusion Soreness/Pain Caught In/Between(pinch,crushed,smashed,cut)撞伤 痛Foreign Object In Eye Strain/Sprain Caught On(snagged,hung)异物入眼 扭伤Fracture Other Contact with electricity/heat/cold/toxic/noise骨折 其它 接触电流/热/冷/有毒物质/噪音Overstress,Overexertion,Over load疲劳过度，超负荷Repetitive Motion 反复性动作Foreign Object In Eye异物入眼Unknow 未知Other 其它SECTION 66.What location or area did the incident take place?(Please be specific)事故发生地点或区域？(要求详细说明)_ _What are some factors that may have contribute to the incident?可能引起事故的一些困素？_ _What ate the possible root causes?可能的根本原因是什么？_ _What were the immediate containment actions?有哪些及时的制止措施？_ _ _Were safe Guards or Safety Equipment Provided?Yes No N/A If yes ,were they used? Yes No是否有保安或安全设备？是 否 不适用 如有，是否使用？ 是 否Was there any property damage or loss? Yes No N/A Amount If yes,Please describe:是否有任何财产损失? 是 否 不适用 金额 如有，请描述;_SECTION 77.Recommendations for Corrective Actions if Any:处理措施建议：_ Team leader Signature Date小组领导签字：_ 日期：_Department Manager Signature： Date部门经理签字：_ 日期：_Classification： Near Miss/Occurrence Medical Aid First Aid Lost Time分类 幸免/发生 医疗救助 急救 错过时间 SECTION 8 TO BE COMPLETED BY THE HEALTH AND SAFETH DEPARTMENT8. 由卫生安全部门填写 Reviewed By Date Received 检查人员：_ 接收日期：_Please provide signed original accident/incident form t