Burn Concussion Crush / Internal Injury Cuts/ Laceration / Open Hearing Loss / Deafness Dislocation Wound Electric Shock Foreign Body under Skin Fracture Foreign Body in Eye Infectious Disease Hernia Musculoskeletal Disorder - Heat Related Illness Occupational Illness / Disease Chronic / RSI Poisoning / Toxic Effect - Nerve / Spinal Cord Injury Psychological (Stress) Ingestion Poisoning / Toxic Effect – Strain / Sprain Respiratory Disease Inhalation Skin Irritation / Disease Other ________________ Other _____________ Bite / Sting Biological Factors Cave-In or Collapse Dust / Fumes / Gases Chemicals / Substances / Drowning / Submersion Radiation Equipment / Property Damage Extreme Temperature / Fire Electricity Fall from Height Mechanism of Injury / Illness: Hit by Moving Object / Crush / Manual Handling Mental Stress Vehicle Occupational Violence Penetrating Injury (needle stick, puncture wound) Repetitive Motion Slip, Trip and Fall Sound / Pressure Struck by Falling Object Other Unspecified Mechanism: Animal / Human Confined Space Environmental Conditions Materials or Chemical Fixed Machinery / Plant Infectious Agent Substances Agency / Source of Mobile Plant / Equipment Non-Powered Equipment / Tools / Appliances Injury / Illness: Powered Equipment / Tools / Road Transport / Vehicles Scaffolding or Ladders Appliances Sharps / Scalpels / Needles / Trench or Excavations Other etc. Cervical Spine Ear Eye Head / Neck Face (excluding eye) Forehead Mouth Neck Nose Scalp / Skull Abdomen Back Genitals Trunk Pelvis Spine Thorax Clavicle (Collar Bone) Elbow Fingers (other than Thumbs) Upper Forearm Hand Shoulder Extremity Thumb Upper Arm Wrist Bodily Location: Ankle Buttocks Foot Lower Hip / Groin Knee Lower Leg Extremity Thigh Toes Arteries Brain Heart Internal Organs Intestines Kidney Liver Lungs Spleen Stomach General Heat Related Occupational Illness Other: 3. Additional Information: (additional information to complete the investigation as required by clause 5.4 of OSHAD-SF Mechanism 11.0 - to include information not already covered by Form G1.)
Burn Concussion Crush / Internal Injury Cuts/ Laceration / Open Wound Hearing Loss / Deafness Dislocation Electric Shock Foreign Body under Skin Fracture Foreign Body in Eye Infectious Disease Hernia Heat Related Illness Occupational Illness / Disease Musculoskeletal Disorder - Chronic / RSI Nerve / Spinal Cord Injury Psychological (Stress) Poisoning / Toxic Effect - Ingestion Poisoning / Toxic Effect – Inhalation Strain / Sprain Respiratory Disease Skin Irritation / Disease Other ________________ Other _____________ Mechanism of Injury / Illness: Bite / Sting Biological Factors Cave-In or Collapse Chemicals / Substances / Radiation Drowning / Submersion Dust / Fumes / Gases Equipment / Property Damage Extreme Temperature / Fire Electricity Fall from Height Hit by Moving Object / Crush / Vehicle Manual Handling Mental Stress Occupational Violence Penetrating Injury (needle stick, puncture wound) Repetitive Motion Slip, Trip and Fall Sound / Pressure Struck by Falling Object Other Unspecified Mechanism: Agency / Source of Injury / Illness: Animal / Human Confined Space Environmental Conditions Fixed Machinery / Plant Infectious Agent Materials or Chemical Substances Mobile Plant / Equipment Non-Powered Equipment / Tools / Appliances Powered Equipment / Tools / Appliances Road Transport / Vehicles Scaffolding or Ladders Sharps / Scalpels / Needles / etc. Trench or Excavations Other Bodily Location: Head / Neck Cervical Spine Ear Eye Face (excluding eye) Forehead Mouth Neck Nose Scalp / Skull Trunk Abdomen Back Genitals Pelvis Spine Thorax Upper Extremity Clavicle (Collar Bone) Elbow Fingers (other than Thumbs) Forearm Hand Shoulder Thumb Upper Arm Wrist Lower Extremity Ankle Buttocks Foot Hip / Groin Knee Lower Leg Thigh Toes Internal Organs Arteries Brain Heart Intestines Kidney Liver Lungs Spleen Stomach General Heat Related Occupational Illness Other: 3. Additional Information: (additional information to complete the investigation as required by clause 5.4 of OSHAD-SF Mechanism 11.0 - to include information not already covered by Form G1.)
5_12_For_Tag.docx