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: ___________________