Employee Health Incident Investigation Report
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Formula-generated average cost Average hourly wage plus fringe benefits for this job Injured body part: Head, face Back Hip Eye Rib Leg, knee Neck, shoulder Hernia, rupture Foot, ankle Injury type: Burn Fracture Amputation Bruise, abrasion Hearing loss Arm, elbow Toe Strain, sprain, crush or mash Cut, puncture or laceration Chest, lower trunk Heart attack Thumb, finger Wrist, hand Other (estimate work hours lost: hours) Death Other Formula-generated cost estimate (from computer calculation) Yes No Do you use ANSI Z16.2 coding If no, proceed to Causal factors..
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