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_____________________________________________________________________________