OSHA RECORDABLE CASES
EMPLOYER
Name________________________________________________________________________________
Address____________________________________________________________________Zip________
INJURED EMPLOYEE
Name________________________________________________________________________________
Description of
Injury____________________________________________________________________
_____________________________________________________________________________________
Date of
Injury__________________________________________________________________________
Task Being
Performed____________________________________________________________________
_____________________________________________________________________________________
(Operation, Set-Up, Maintenance or Others - Be Specific)
PRESS DESCRIPTION
Type of Press
Clutch_____________________________________________________________________ (Full Revolution, Part
Revolution or Direct Drive)
Type of Safeguards Being
Used_____________________________________________________________
_______________________________________________________________________________________
(2-Hand Control; 2-Hand Trip; Fixed Barrier Guard; Adjustable Barrier
Guard; Type"A" Gate or Movable Barrier Guard; Type "B" Gate or Movable
Barrier Guard; Presence Sensing Device; Pull Outs, Restraints, Hold Outs;
etc.)
ACCIDENT CAUSE
Cause of
Accident_______________________________________________________________________
______________________________________________________________________________________
(Repeat of Press; Safeguard Failure; Removing Stock Part of Scrap; No
Safeguard Provided; Safeguard Provided but not Being Used; Incorrect Control
Mode Used or Other; Improper Usage of Adjustment; Be Specific)
MACHINE LOADING
Type of
Feeding________________________________________________________________________
_____________________________________________________________________________________
(Manual with Hands in Die or with Hands Out of Dies; with Hand Tools;
Semi-Automatic or Others; Be Specific)
PRESS ACTUATION
Means Used to Actuate Press
Stroke________________________________________________________
______________________________________________________________________________________
(Foot Trip; Foot Control; Hand Trip; Hand Control; Be Specific)
OPERATORS
Number of Personnel Required for
Operation________________________________________________________________________
Number of Operators Provided with Controls and
Safeguards_________________________________________________________
DATE OF
REPORT______________________________________________________________________________
PREPARED
BY___________________________________________________________________________________
OFFICIAL
POSITION_____________________________________________________________________________
|