Tool: Ergonomic Injuries Data Summary and Corrective Actions

HOW TO USE THIS TOOL

Once you gather ergonomic injury records and analyze the data, you must translate your findings into corrective actions. This tool will help you do this. This a Model Form that summarizes data collected on all the Ergonomic Injury Record Review Forms that were completed.

Fill out a summary form for each type of ergonomically related injury suffered by your workers.

Using this form will enable you to organize your injury data, determine appropriate corrective action, and establish priorities.

Instructions: Please fill out a separate version of this form for each ergonomically related injury type identified by the records review.

TYPE OF INJURY: ___________________

Total Occurrences: ___________________

Occurrences by Department/Operation

Dept.: ___________________ Incidents: _________

Dept.: ___________________ Incidents: _________

Dept.: ___________________ Incidents: _________

Dept.: ___________________ Incidents: _________

Occurrences by Job Title

Title: ___________________ Incidents: _________

Title: ___________________ Incidents: _________

Title: ___________________ Incidents: _________

Title: ___________________ Incidents: _________

Occurrences by Equipment, Device, Workstation, etc.

Equip. (include serial no.): ___________________ Incidents: _________

Equip: ___________________ Incidents: _________

Equip: ___________________ Incidents: _________

Equip: ___________________ Incidents: _________

Recommended Corrective Actions (list in order of priority)

______________________________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

Prepared By: ___________________

Signature: ___________________

Date: ___________________