Head Face Neck Shoulder Hip Eyes Back upper Upper arm Leg upper Ear Back lower Elbow Knee Nose Chest Forearm Leg lower Mouth Abdomen Wrist Ankle Head – multiple Groin / pelvic region Hands, Foot / toes fingers & locations Trunk – multiple Lower limb – multiple thumb locations locations Upper limb – multiple locations Name of injured person Signature (please print) Date If not injured person Name: Signature (please print) Date Name of Manager/Supervisor confirming receipt of report Signature (please print) Date Section C: Incident / Hazard Investigation & Control
Head Face Eyes Ear Nose Mouth Head – multiple locations Neck Back upper Back lower Chest Abdomen Groin / pelvic region Trunk – multiple locations Shoulder Upper arm Elbow Forearm Wrist Hands, fingers & thumb Upper limb – multiple locations Hip Leg upper Knee Leg lower Ankle Foot / toes Lower limb – multiple locations Name of injured person (please print) Signature Date If not injured person Name: (please print) Signature Date Name of Manager/Supervisor confirming receipt of report (please print) Signature Date Section C: Incident / Hazard Investigation & Control