Timber Build, Inc Accident Report
Date of Report
*
-
Month
-
Day
Year
Date
Incident Reporter
*
First Name
Last Name
Incident Reporter Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Witnesses
*
First Name
Last Name
Witnesses Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
1. Personal Information of the Injured Person
Position
*
Please Select
Woodworker
Shipping
Manager Shop
Lumber Yard Handling
Shop Cleaning
Sales Office
Manager Office
Executive
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
2. Incident Details
Date of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
125 Business Dr SW Lilburn, Ga 30047
Other
3. Injury Details
Severity of Injury
*
Minor
Moderate
Severe
Life-Threatening
Fatal
Minor Selection
*
Minor cuts, bruises, or abrasions.
Small splinters or foreign bodies in the skin.
Minor burns or irritations.
Temporary discomfort or pain that does not interfere significantly with normal activities.
Other
Moderate Selection
*
Lacerations requiring stitches.
Moderate burns.
Sprains or strains that may limit mobility or require medical treatment.
Foreign bodies in the eye requiring professional removal.
Temporary hearing loss or ringing in the ears.
Respiratory irritation requiring medical evaluation.
Other
Severe Selection
*
Deep lacerations with potential tendon, muscle, or nerve damage.
Broken bones or fractures.
Serious burns requiring immediate medical treatment.
Amputations or serious crushing injuries.
Head injuries with symptoms of concussion or more serious conditions.
Permanent or long-term impairment or disability.
Other
Life-Threatening Selection
*
Injuries requiring immediate life-saving intervention.
Severe head trauma.
Major burns covering a significant area of the body.
Injuries causing severe blood loss.
Respiratory failure or chemical inhalation causing critical symptoms.
Other
Nature of Injury
*
Cuts or Lacerations: Injuries caused by sharp tools or materials, such as saws or chisels.
Abrasions: Skin injuries caused by scraping or rubbing against rough surfaces.
Punctures: Injuries caused by objects piercing the skin, such as nails or splinters.
Crush Injuries: Injuries resulting from being squeezed, trapped, or crushed by machinery, materials, or heavy objects.
Burns: Thermal burns from hot materials or tools or chemical burns from finishes, adhesives, or other substances.
Eye Injuries: This could include foreign objects in the eye, chemical splashes, or injuries from flying debris.
Hearing Damage: Long-term exposure to loud machinery without proper ear protection can lead to hearing loss.
Respiratory Issues: Inhalation of dust or chemical fumes causing respiratory irritation or long-term health issues.
Musculoskeletal Injuries: Strains, sprains, or more severe injuries due to lifting, repetitive motions, or awkward postures.
Electric Shock: Injuries caused by contact with electrical sources.
Amputations: Loss of a limb or digit, often due to contact with cutting machinery.
Concussions or Head Injuries: Caused by falling objects or bumps against stationary objects.
Other
Part of Body Affected
*
Hands or Fingers
Eyes: At risk from flying debris, splinters, or chemical splashes.
Arms or Wrists: Injuries here may be due to machine operation, lifting, or repetitive motions.
Legs or Feet: Can be affected by heavy lifting, falls, or accidents involving larger machinery.
Back: Strain or injury due to lifting, bending, or awkward postures.
Head: Injuries from falling objects, bumps against equipment, or slips and falls.
Chest or Abdomen: Less common, but can be affected in accidents involving larger machinery or falling materials.
Neck or Shoulders: Strains or injuries from lifting, carrying, or repetitive motion.
Lungs: Injuries or conditions caused by inhalation of dust or chemical fumes.
Ears: Affected by long-term exposure to loud noise without adequate hearing protection.
Face: Injuries can occur from flying debris, tools, or materials.
Skin: General area for cuts, abrasions, burns, or allergic reactions.
First Aid Administered
*
Yes
No
Type of First Aid Given
*
Cleansing and Dressing Wounds
Splinter Removal
Applying Ice Packs or Cold Compresses
Elevating Injured Limbs
Applying Bandages
Applying Pressure to Control Bleeding
Immobilizing Injured Body Parts
Flushing Eyes
CPR (Cardiopulmonary Resuscitation)
Assisting with Breathing Difficulties
Administering Pain Relief (e.g., over-the-counter painkillers)
Treating Burns (cooling and covering)
Administering Antiseptic Cream or Spray
Using a Tourniquet (in extreme cases of bleeding)
Providing Shock Management
Treating Chemical Exposure
Administering Allergy Medication (e.g., antihistamines for allergic reactions)
Providing Heat for Hypothermia or Cold Exposure
Using an Automated External Defibrillator (AED)
Providing Emotional Support and Reassurance
Describe First Aid Given
4. Incident Description
Description of What Happened
*
Provide a detailed account of the events leading up to, during, and immediately following the accident. Include what the individual was doing at the time.
Medical Attention Required
*
No
Yes
Type of Medical Attention
*
Emergency Care
Delayed Care - After Work
Transportation to Medical Facility
*
Private Vehicle
Ambulance
Other
Transported By Name
*
First Name
Last Name
Phone Number (Transported By)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Facility Name
*
SUBMIT
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