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    ___________________________________________ Body Part Head Face Neck Shoulder Upper Arm Elbow Forearm Wrist Hand Finger Chest Abdomen Back Hip Buttock Thigh Knee Lower Leg Ankle Foot Toe Eye Ear Nose Mouth Teeth Internal External Multiple Whole Body Psychological Others (Specify) Code Injury I1 I2 I3 I4 I5 I6 I7 I8 I9 I10 I11 I12 I13 Abrasion Bru

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    ___________________________________________ Body Part Head Face Neck Shoulder Upper Arm Elbow Forearm Wrist Hand Finger Chest Abdomen Back Hip Buttock Thigh Knee Lower Leg Ankle Foot Toe Eye Ear Nose Mouth Teeth Internal External Multiple Whole Body Psychological Others (Specify) Code Injury I1 I2 I3 I4 I5 I6 I7 I8 I9 I10 I11 I12 I13 Abrasion Bru

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    © All Rights Reserved
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    Download as xlsx, pdf, or txt
    19 views2 pages

    Accident Medical Report Form

    Uploaded by

    RaymondGomezBlanco
    ___________________________________________ Body Part Head Face Neck Shoulder Upper Arm Elbow Forearm Wrist Hand Finger Chest Abdomen Back Hip Buttock Thigh Knee Lower Leg Ankle Foot Toe Eye Ear Nose Mouth Teeth Internal External Multiple Whole Body Psychological Others (Specify) Code Injury I1 I2 I3 I4 I5 I6 I7 I8 I9 I10 I11 I12 I13 Abrasion Bru

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    of 2

    ACCIDENT MEDICAL REPORT

    Document
    No:
    Revision:
    Issue Date:
    Page:

    SANR-HSE Form 19
    0
    12/27/2014
    1 of 6

    PERSONAL INFORMATION
    Name:

    REVIEWED

    I.D. No.:

    Department:

    PM5

    PM6

    Internal Production

    EO1 / EC1 / OF1 / PT1 / MC1 / QA1

    EO2 / EC2 / OF2 / PT2 / MC2 / QA2

    IO / FB / PN / AS / SA / PO / BP / QA3

    Production

    OP

    Quality Assurance

    O&M

    OTHERS

    PS / WT / EN / TR

    OP

    QAPL / QAH / QAO /QAPT

    OMC / OFC / OEL / OEC

    AM / HSE / SS / HT / HP / HC / SC / SD

    Entering Date: ______________ <1M

    >1M-1Y

    >1Y-2Y

    >2Y

    Unit:

    ____________________

    Nurse

    ACCIDENT INFORMATION
    Date of Accident:

    _______ / _______ / __________

    Place of Accident:
    Accident Type:
    Injury Type:

    A1
    I1

    A2
    I2

    Day:

    Time:

    __________

    Th
    AM

    PM

    F
    NS

    S
    OT

    BT

    A3

    A4

    A5

    A6

    A7

    A8

    A9

    A10

    A11

    A12

    A13

    I3

    I4

    I5

    I6

    I7

    I8

    I9

    I10

    I11

    I12

    I13

    Su
    B/AW
    A14

    Details of Accident:

    Patient / Witness:________________________________

    HSE Staff:________________________________________

    ANATOMICAL
    Code
    B1
    B2
    B3
    B4
    B5
    B6
    B7
    B8
    B9
    B10
    B11
    B12
    B13
    B14
    B15
    B16
    B17
    B18
    B19
    B20
    B21
    B22
    B23
    B24
    B25
    B26
    B27
    B28
    B29
    B30
    B31
    B32

    Attending Physician:____________________________________
    SANR-HSE Form-19

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