NAILOR
Total Reportable Incident
Incident Details
D.O.I.
*
Location
*
— Select location —
Winfield
Mesa
Chicago
Rankin
Vegas
Department
Brief Summary
*
Injury Classification
Nature of Injury
— Select —
Sprain/Strain
Fracture
Laceration
Contusion
Abrasion
Body Part
— Select —
Back
Toe/s
Hand
Finger/s
Arm
Shoulder
Ankle
Foot
Leg
Knee/s
Eye
Multiple
Other
Cause
— Select —
Slip/Fall Same Level
Slip/Fall From Spill
Slip/Fall Ladder
Trip
Struck By Handled Object
Struck Against Object
Struck Against Stnry Obj
Struck By Fall/Flying Obj
Struck By Hand Tools
Cut by Material Handled
Cut by Nonpower Hand Tool
Object Lift/handled
Caught in Machinery
Frgn Body in Eye
Incident Type
Mutually exclusive — select the highest applicable severity tier.
First Aid Only
No off-site treatment
Clinic Visit
Off-site medical treatment
Lost Time
Employee missed work
# L/T Days
Restricted Days
# R/D
Classification & Completion
Recordable
Step 1 Completed
by Manager
Step 5 Completed
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