PLEASE TYPE OR PRINT

 ___ AA AUTO ACCIDENT

____ AB CONTACT WITH SKIN IRRITANT

____ AC INSECT BITE OR STING

____ AD POISONING

____ AE EXTREME NOISE

____ AF ANIMAL BITE

____ AG OVEREXERTION

____ AH STROKE

____ AI HEART ATTACK

____ AJ MENTAL STRESS

____ AK TRAUMATIC NEUROSIS

____ AL EXPOSURE TO OCCUPATIONAL DISEASE

____ AM INHALATION OF CHEMICALS/OTHER IRRITANTS

____ AN FOREIGN BODY IN EYE

____ AR HUMAN BITE

____ 1A STRUCK BY MOVING OBJECT OTHER THAN A VEHICLE

____ 1B STRUCK BY MOTOR VEHICLE

____1C STRUCK BY PATIENT OR EMPLOYEE

____ 2A STRAIN BY LIFTING, TWISTING, OR USING TOOL/MACH

____ 3A SLIP AND FALL ON FOREIGN OBJECT

____ 3B SLIP AND FALL FROM LADDERS, SCAFFOLDING, & CHAIRS

____ 3C SLIP AND FALL FROM RAMPS, CURBING, OR STAIRS

____ 4A STRIKING AGAINST OBJECT

____ 5A STEPPING ON A SHARP OBJECT

____ 6A CAUGHT IN / BETWEEN MACHINERY OR OTHER OBJECTS

____ 7A BURN OR EXPOSURE DUE TO PHYSICAL CONTACT

____ 7B BURN OR EXPOSURE INVOLVING WELDING

____ 7C BURN OR EXPOSURE TO EXTREME HEAT OR COLD

____ 7D BURN OR EXPOSURE INVOLVING CHEMICALS

____ 7E BURN OR EXPOSURE INVOLVING ELECTRICITY

____ 8A CUT, PUNCTURE OR SCRAPE BY A TOOL

____ 8B CUT, PUNCTURE OR SCRAPE INVOLVING GLASS

____ 8C CUT, PUNCTURE OR SCRAPE BY A SHARP OBJECT

____ 9A TRIPPING

___ A NEW ORLEANS

___ B BATON ROUGE

___ C LAKE CHARLES

___ D SHREVEPORT

___ E ALEXANDRIA

___ F LAFAYETTE

___ G MONROE

___ Z CITY NOT LISTED

___ O RURAL AREA

___ I INTERNATIONAL

___ 1 SUNDAY

___ 2 MONDAY

___ 3 TUESDAY

___ 4 WEDNESDAY

___ 5 THURSDAY

___ 6 FRIDAY

___ 7 SATURDAY

__ A 12:01AM-1:00AM

__ B   1:01AM-2:00AM

__ C   2:01AM-3:00AM

__ D   3:01AM-4:00AM

__ E   4:01AM-5:00AM

__ F   5:01AM-6:00AM

__ G   6:01AM-7:00AM

__ H   7:01AM-8:00AM

__ I    8:01AM-9:00AM

__ J    9:01AM-10:00AM

__ K 10:01AM-10:00AM

__ L 11:01AM-12:00PM

__ M 12:01PM- 1:00PM

__ N   1:01PM- 2:00PM

__ O   2:01PM- 3:00PM

__ P   3:01PM- 4:00PM

__ Q   4:01PM- 5:00PM

__ R   5:01PM- 6:00PM

__ S   6:01PM- 7:00PM

__ T   7:01PM- 8:00PM

__ U   8:01PM- 9:00PM

__ V   9:01PM-10:00PM

__ W 10:01PM-11:00PM

__ X 11:01PM-12:00AM

FIELD 36—NEED LOSS

PREVENTION OFFICER

ASSISTANCE  __Y  __N

___ AA AMPUTATION

___ AB ANIMAL BITE

___ AC BRUISE/CONTUSION/SWELLING

___ AD BURN/ABRASION/REDNESS

___ AE CONCUSSION

___ AF DEATH

___ AG DEPRESSION AND ANXIETY

___ AH DERMATITIS

___ AI DISLOCATION OR SEPARATION

___ AJ ELECTRICAL SHOCK OR BURN

___ AK EYE IRRITATION/DAMAGE

___ AL FRACTURE

___ AM HEARING IMPAIRMENT

___ AN HEART ATTACK

___ AP HEAT STROKE

___ AQ HERNIA

___ AR HERNIATED DISC

___ AS INSECT BITE/STING

___ AT LACERATION

___ AU LOSS OF VISION

___ AV SMASHED OR CRUSHED

___ AW MENTAL ANGUISH

___ AX MULTIPLE INJURIES

___ AY POISONING

___ AZ PUNCTURE

___ BA PROSTHETIC REPLACEMENT

___ BB SEIZURE

___ BC SPRAIN/STRAIN

___ BD STRESS

___ BE STROKE

___ HB HUMAN BITE

___ FEMALE

___ MALE

___ 0   LESS THAN 6 MOS.

___ 1   7 MOS.-1 YEAR

___ 2   1-3 YEARS

___ 3   3-5 YEARS            

___ 4   5-10 YEARS

___ 5   10-15 YEARS

___ 6   MORE THAN 15 YEARS

___ A 15-17              ___ H 51-55

___ B 18-21               ___ I 56-60

___ C 22-25               ___ J 61-65

___ D 26-30               ___ K OVER 65

___ E 31-35

___ F 36-40

___ G 41-50

___ AA HEAD

___ AG JAW

___ BB BACK

___ BH GROIN

___ CC ELBOW

___ DB THIGH

___ DH TOE

___

___ AB FOREHEAD

___ AH TEETH

___ BC CHEST

___ BI GENITAL

___ CD WRIST

___ DC KNEE

___ BK SPINE

___ AC EYE

___ AI FACE

___ BD RIBS

___ BJ BUTTOCK

___ CE HAND

___ DD LEG

___ DE SKIN

___ AD EAR

___ AJ CHEEK

___ BE STOMACH

___ BL INTERNAL

___ CF THUMB

___ DF ANKLE

___ AE NOSE

___ AK THROAT

___ BF LUNGS

___ CA SHOULDER

___ CG FINGER

___ DG FOOT

___ AF MOUTH

___ BA NECK

___ BG HEART

___ CB ARM

___ DA HIP

UNSAFE ACT (PRIMARY):

UNSAFE CONDITION (PRIMARY):

CONTRIBUTORY FACTORS (IF ANY):

WHY WAS ACT COMMITTED:

WHY DID CONDITION EXIST:

IMMEDIATE ACTION TAKEN TO PREVENT RECURRENCE:

LONG RANGE ACTION TO BE TAKEN:

WHAT ADDITIONAL ASSISTANCE IS NEEDED TO PREVENT RECURRENCE: