APPENDIX 4 OCCUPATIONAL HEALTH AND SAFETY – OHS Occurrence Report Report No. Occurrence Date Time Reported to Time Reported to AU Time Supervisor OHS Occurrence Class: Other: Work Relation: Other: Occurrence Location: Other: Occurrence Area: Specific Location: Nature of Occurrence: Other: Source of Occurrence: Other: Bio Hazard Deafness, Hearing Loss, Influenza Respiratory Nature of Injury: Burns Impairment Lacerations Poisonings and Toxic Effects N/A Carpal Tunnel Dermatitis Mental Health / Psychological Skin and Subcutaneous Tissue Animal or Insect Bites or Circulatory Epicondylitis Neoplasms, Tumors, and Cancer Strain or Sprain Venomous Concussion Foreign Body Nervous System Systemic Asphyxia Contusions / Fractures Non-Personal (Personal effects only) Tendonitis Benign Bruises H1N1 Influenza Nonspecific Injuries and Disorders Trauma Neoplasms/Tumors Crushing Head – Severe Other, please comment: Injuries Hernia – Rupture Part of Body Ear Head and Face Neck Unknown Elbow Hip and Thigh Personal effects only (no bodily injury) Wrist Injured: Eyes Internal Systems Shoulder and Upper Arm Other, please comment: Abdomen/Pelvis Face Knee Teeth/Mouth Ankle Finger(s) Leg Trunk Right Left or Both Arm Foot Multiple Systems Back Hand Brain Chest Person(s) Involved in Department Supervisor Name Occurrence N/A Injured Person(s) Department Supervisor name Description of Occurrence:
APPENDIX 4 OCCUPATIONAL HEALTH AND SAFETY – OHS Occurrence Report Report No. Occurrence Date Time Reported to Supervisor Time Reported to AU OHS Time Occurrence Class: Other: Work Relation: Other: Occurrence Location: Other: Occurrence Area: Specific Location: Nature of Occurrence: Other: Source of Occurrence: Other: Nature of Injury: N/A Animal or Insect Bites or Venomous Asphyxia Benign Neoplasms/Tumors Bio Hazard Burns Carpal Tunnel Circulatory Concussion Contusions / Bruises Crushing Injuries Deafness, Hearing Loss, Impairment Dermatitis Epicondylitis Foreign Body Fractures H1N1 Influenza Head – Severe Hernia – Rupture Influenza Lacerations Mental Health / Psychological Neoplasms, Tumors, and Cancer Nervous System Non-Personal (Personal effects only) Nonspecific Injuries and Disorders Respiratory Poisonings and Toxic Effects Skin and Subcutaneous Tissue Strain or Sprain Systemic Tendonitis Trauma Other, please comment: Part of Body Injured: Abdomen/Pelvis Ankle Arm Back Brain Chest Ear Elbow Eyes Face Finger(s) Foot Hand Head and Face Hip and Thigh Internal Systems Knee Leg Multiple Systems Neck Personal effects only (no bodily injury) Shoulder and Upper Arm Teeth/Mouth Trunk Unknown Wrist Other, please comment: Right Left or Both Person(s) Involved in Occurrence Department Supervisor Name N/A Injured Person(s) Department Supervisor name Description of Occurrence:
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