完整的外企事故调查分析表(中英文).doc

Site: 工厂： Report Number: 报告编号 Year / sequence number (e.g. 2007/001) 年份/序列号 (如：2007/001) Sections A,B C – These sections are to be completed by the Site Accident Investigation Team. 单元A,B和C — 由工厂事故调查组填写 Section A 单元 A Lost Time Accident 事故损失 □ Incident 失误 □ Minor Injury 小事故 □ Number of working days lost: 事故损失天数 Date: 日期 Time: 时间 Department: 部门 Equipment/Process: 设备/过程 Personnel details 员工详细资料 Name: 姓名 Job Title: 职位 Date of Birth: 出生日期 Next of Kin: 直系亲属： Years of Service: 在职年限 Home Address: 家庭住址 Fully Trained in Task YES □ NO □ 是否经过培训 是 否 First Aid Treatment 急救 Details of Injury: 受伤详细情况 Treatment Provided: 提供的治疗 Person who Administered First Aid: 现场急救人员 Hospital/Clinic Details (if applicable): 医院/门诊部门治疗记录： Section B 单元 B Details of Lost Time Accident / Incident / Minor Injury: 事故损失/失误/小事故调查详细情况 Continue on additional pages if necessary如需要，请转附页填写 Controls in place to prevent Lost Time Accident/Incident/Minor Injury – indicating where the controls were not followed or failed: 防止事故损失/失误/小事故的发生，指出防患安全漏洞或措施不当之处 Continue on additional pages if necessary如需要，请转附页填写 Identification of the causes of Lost Time Accident/Incident/Minor Injury: 导致事故损失/失误/小事故的起因鉴定 Immediate action already taken to prevent recurrence: 立即采取措施，防止再次发生 Additional action required in order to prevent recurrence: 要求附加的措施以防止再次发生 Continue on additional pages if necessary如需要，请转附页填写 Action required 要求的措施 Responsibility 责任 Completion Date 完成日期 Section C 单元 C Accident Investigation Team Sign-off: 事故调查组人员签名 Name: Position: Signature: 姓名