More examples in Healthcare/Medical Examination Reports
Work Related Medical Examination Example
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HOW MUCH EXPERIENCE DID THE DECEDENT HAVE PERFORMING THIS PARTICULAR TASK? WHAT IS DECEDENT' S PERFORMANCE RECORD ACCORDING TO FELLOW WORKERS? WHAT IS DECEDENT'S PERFORMANCE RECORD ACCORDING TO THE SUPERVISOR? DOES DECEDENT HAVE ANY KNOWN HISTORY OF ALCOHOL OR DRUG USE WHILE ON THE JOB? WAS THE DECEDENT SUPPOSED TO BE ON MEDICATIONS DURING WORK HOURS? OSHA WAS CONTACTED: YES NO IF YES, NAME/TEL OF PERSON CONTACTED: MSHA WAS CONTACTED: YES NO IF YES, NAME/TEL OF PERSON CONTACTED: NAME OF INVESTIGATOR DMI# WORK RELATED NAME OF DECEDENT: This form is to completed in addition to the ROD form in these guidelines THE SCENE DESCRIBE THE SCENE GENERALLY: WHERE WAS DECEDENT FOUND WITH REFERENCE TO ANY EQUIPMENT IN THE AREA? DESCRIBE THE EQUIPMENT, IF ANY: WAS THE DECEDENT MOVED BY ANYONE, IF SO BY WHOM AND WHERE TO? DOES THE INFORMANT RECALL EXACT LOCATION OF THE DECEDENT WITH REFERENCE TO
EQUIPMENT AT THE SCENE? DESCRIBE THE DECEDENT'S EXACT POSITION WHEN ORIGINALLY FOUND: WERE SAFETY PRECAUTIONS POSTED IN OR AROUND THE MACHINERY OR EQUIPMENT? IS THERE ANY INDICATION THAT SAFETY PRECAUTIONS WERE OBSERVED? WAS DECEDENT DRESSED APPROPRIATELY FOR WORKING WITH THE MACHINERY OR
EQUIPMENT? WHAT SAFETY GEAR IS GENERALLY REQUIRED FOR WORKING AROUND THIS PARTICULAR
MACHINERY OR EQUIPMENT? IS THERE ANY INDICATION THAT THE SAFETY EQUIPMENT WAS DEFECTIVE (DESCRIBE)? WHAT WAS DECEDENT SUPPOSED TO BE DOING AT THE TIME OF INCIDENT? WAS INCIDENT OBSERVED (DOES INFORMANT GIVE ACCOUNT CONSISTENT WITH FINDINGS)? POSSIBLE CONTRIBUTING FACTORS: HUMAN ELEMENT MACHINE FAILURE POSSIBLE ELECTRICAL CONTACT EXPOSURE TO SOLVENT OR FUMES OTHER CHEMICAL VAPORS EXPLOSION FIRE UNKNOWN (EXPLAIN): WAS ANYONE ELSE IN THE AREA EITHER SICK OR INJURED OR KILLED? HAS SIMILAR OCCURRENCE OR "CLOSE CALL" HAPPENED IN THE PAST? HAS WORK AREA CHANGED IN ANY WAY RECENTLY? THE BUSINESS EMPLOYER'S NAME & ADDRESS & TELEPHONE NUMBERS: SUPERVISOR'S NAME: PRODUCT OR SERVICE PROVIDED BY THIS BUSINESS? HOW LONG HAS BUSINESS BEEN IN OPERATION? IS BUSINESS COVERED BY WORKMENS COMPENSATION? IS BUSINESS COVERED BY OTHER INSURANCE? IS BUSINESS UNIONIZED? IS THERE ANY RECORD OF COMPLAINTS (VOICED OR IN WRITING) BY EMPLOYEES? THE DECEDENT DECEDENT'S OFFICIAL JOB TITLE: (ATTACH COPY OF JOB DESCRIPTION IF AVAILABLE, IF NOT, DESCRIBE) WAS AN EMPLOYMENT APPLICATION FILLED OUT? DATE OF INITIAL EMPLOYMENT? POSITION(S) HELD WITH THIS BUSINESS? OTHER RELATED EXPERIENCE? WAS DECEDENT PERFORMING A TASK HE/SHE WAS TRAINED TO DO?
EQUIPMENT AT THE SCENE? DESCRIBE THE DECEDENT'S EXACT POSITION WHEN ORIGINALLY FOUND: WERE SAFETY PRECAUTIONS POSTED IN OR AROUND THE MACHINERY OR EQUIPMENT? IS THERE ANY INDICATION THAT SAFETY PRECAUTIONS WERE OBSERVED? WAS DECEDENT DRESSED APPROPRIATELY FOR WORKING WITH THE MACHINERY OR
EQUIPMENT? WHAT SAFETY GEAR IS GENERALLY REQUIRED FOR WORKING AROUND THIS PARTICULAR
MACHINERY OR EQUIPMENT? IS THERE ANY INDICATION THAT THE SAFETY EQUIPMENT WAS DEFECTIVE (DESCRIBE)? WHAT WAS DECEDENT SUPPOSED TO BE DOING AT THE TIME OF INCIDENT? WAS INCIDENT OBSERVED (DOES INFORMANT GIVE ACCOUNT CONSISTENT WITH FINDINGS)? POSSIBLE CONTRIBUTING FACTORS: HUMAN ELEMENT MACHINE FAILURE POSSIBLE ELECTRICAL CONTACT EXPOSURE TO SOLVENT OR FUMES OTHER CHEMICAL VAPORS EXPLOSION FIRE UNKNOWN (EXPLAIN): WAS ANYONE ELSE IN THE AREA EITHER SICK OR INJURED OR KILLED? HAS SIMILAR OCCURRENCE OR "CLOSE CALL" HAPPENED IN THE PAST? HAS WORK AREA CHANGED IN ANY WAY RECENTLY? THE BUSINESS EMPLOYER'S NAME & ADDRESS & TELEPHONE NUMBERS: SUPERVISOR'S NAME: PRODUCT OR SERVICE PROVIDED BY THIS BUSINESS? HOW LONG HAS BUSINESS BEEN IN OPERATION? IS BUSINESS COVERED BY WORKMENS COMPENSATION? IS BUSINESS COVERED BY OTHER INSURANCE? IS BUSINESS UNIONIZED? IS THERE ANY RECORD OF COMPLAINTS (VOICED OR IN WRITING) BY EMPLOYEES? THE DECEDENT DECEDENT'S OFFICIAL JOB TITLE: (ATTACH COPY OF JOB DESCRIPTION IF AVAILABLE, IF NOT, DESCRIBE) WAS AN EMPLOYMENT APPLICATION FILLED OUT? DATE OF INITIAL EMPLOYMENT? POSITION(S) HELD WITH THIS BUSINESS? OTHER RELATED EXPERIENCE? WAS DECEDENT PERFORMING A TASK HE/SHE WAS TRAINED TO DO?