Classification Salt Lake City Accident/Incident/Near-Miss Report Email to Joshua.davis@Hunterdouglas.com, Part A: General Information Date of Incident: Time of Incident: Business Area (check one): Honeycomb Roller Shades Shutters Maintenance Warehouse Category: Accident Parts Engineering Office Repairs Other Near Miss/Close Call Property Damage Accident Type: (check all that apply) Bodily Reaction Exposure to or contact with Fall from height/same level Fire/Explosion Other Date of First Report: Time of First Report: Product Type (check if applicable): Department (Assembly/Rail/etc.): Honeycomb Roller Shades Shutters Other Exact Location (Equip SAP#, Table#, Room, Pole#, etc.): Was work stopped due to a hazard? Yes No If Yes, please provide details: Harmful substance Illness Material handling (e.g. lifting, carrying) Overexertion Was anyone exposed to body fluids? Yes No If Yes, who? Repetitive motion Slip Struck by/Against Transportation accident Part B: Individual Involved First Name: Last Name: Employee ID Number: Job Title: Shift: Supervisor: Trapped / caught by Trip Use of hand tool Workplace violence Temp. Employee: Yes No Time Employee Began Shift: Part C: Incident Details Describe the incident fully. Include the events leading up to the incident, any equipment or substances involved, any injuries or damage sustained, and any other important details regarding the incident. (Use additional sheet if necessary) Part D: Injury/Illness Details If the incident was a near-miss (no personal injury sustained), skip this section. Nature of Illness/Injury: (check all that apply) Abrasion Concussion Hearing Loss Amputation Cut (Minor) Inflammation Bite Cut (Stitches or Sutures) Irritation Broken Bone Dislocation Loss of Consciousness Bruise Electric Shock Musculoskeletal Disorder Burn Fatality Poisoning Chemical Contamination Foreign Body Penetrating Respiratory Condition Body Part: (check all that apply) Back- Lower Back- Upper Chest Ear Left Right Eye Left Right Face Groin Internal Neck Nose Ribs Torso Head Other Shoulder Upper Arm Elbow Lower Arm Wrist Hand Finger 1 Left Left Left Left Left Left 2 3 Right Right Right Right Right Right 4 5 Skin Disorder Smoke or Fume Inhalation Sprain Strain Upper Limb Disorder (Tendonitis, CTS) Other Buttocks/Pelvis Upper Leg Knee Lower Leg Ankle Foot Toe 1 2 Left Left Left Left Left 3 4 Rev 10/25/2021 Right Right Right Right Right 5 Part E: Causal Factors and Associated Activities: (check all that apply) Contributed to the incident happening. Process Environment/Work Area Inadequate policy/procedure Physical space and layout Inadequate training/education/instruction/JSA Ergonomic factors New task for employee/lack of experience Unsafe working surfaces Rotation schedule Housekeeping issues Equipment People Improper equipment or material used for job Not aware of surroundings Guard removed from equipment Taking shortcuts Emergency stop/release failure/malfunction Eyes on task PPE not effective Horseplay/Carelessness Equipment failure Not following procedures Inadequate guard Distractions/Interruptions Please list any others: Part F: Details of First Aid Measures, if applicable (Band-Aid, wound care, hydrocortisone cream, ice, etc.) Part G: Recommendations to Prevent Recurrence: If an engineer is Person Responsible, include the Engineering Manager and Engineer in Near Miss email. What measures are being taken to prevent this Person responsible Scheduled CI Card incident from recurring? for action completion date Submitted? CI Card Number Part H: Review Supervisors: Please send this document to your Operations Manager, the EHS Department, and the PT’s if there was an injury. Signature: Completed By: Date: Notes (EHS Internal Use Only): Rev 10/25/2021
