Loading ...ERGONOMICS INJURY RECORD REVIEW
Instructions: If you are a member of the records review team, please complete the form below and submit it to the team leader.
A. REVIEWER IDENTIFICATION
Team Leader: ___________________________
Tel. No.: ___________________________
Record Reviewer: ___________________________
Tel. No.: ___________________________
Department: ___________________________
Review Date: ___________________________
B. RECORD IDENTIFICATION
Employee Name (or Record ID number if confidential): ___________________________
Employee Job Title: ___________________________
Record Reviewed: ___________________________
OSHA form ( specify ) ___________________________
Incident report
Workers' comp claim
Other ( specify ) ___________________________
Record Date: ___________________________
C. INJURY IDENTIFICATION
Injury Date: ___________________________
Injury Type ( specify body part(s) affected ) ___________________________
Workplace Location of Injury: ___________________________
Activity Employee Was Performing When Injured: ___________________________
Type of Device, Supply, Equipment or Workstation Involved ( include serial number if applicable )
______________________________________________________
______________________________________________________
______________________________________________________
Reviewer's Signature:___________________________
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[...] trends. We’ll show you how to do an effective records review. We’ve also given you a model form you can use to organize your review that you can access in Tools if you’re a SafetyXChange [...]