Loading ...ERGONOMICS INJURIES: DATA SUMMARY & CORRECTIVE ACTIONS
Instructions: Please fill out a separate version of this form for each ergonomically-related injury type identified by the records review.
TYPE OF INJURY: ___________________
Total Occurrences: ___________________
Occurrences By Department/Operation
Dept.: ___________________ Incidents: _________
Dept.: ___________________ Incidents: _________
Dept.: ___________________ Incidents: _________
Dept.: ___________________ Incidents: _________
Occurrences By Job Title
Title: ___________________ Incidents: _________
Title: ___________________ Incidents: _________
Title: ___________________ Incidents: _________
Title: ___________________ Incidents: _________
Occurrences By Equipment, Device, Workstation, etc.
Equip. (include serial no.): ___________________ Incidents: _________
Equip: ___________________ Incidents: _________
Equip: ___________________ Incidents: _________
Equip: ___________________ Incidents: _________
Recommended Corrective Actions ( list in order of priority )
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Prepared By: ___________________
Signature: ___________________
Date: ___________________
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[...] action. Here’s how to analyze the data and decide on corrective action. There’s also a model form that you can use to help develop and prioritize your plan of action. If you’re a [...]