PRIVATE AND PROTECTED INFORMATION

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NOT FOR PUBLIC RELEASE

Accident Reporting Information

(Last Updated 11/08/2017)

Notification Information
Call Received By: Sharon Glisson (F1283) Date Reported: Thursday, February 4, 2021 Time Reported: 7:15 p.m.
Reported By: Employer If Other, Who Reported the Accident:
Name of Person Reporting Accident: Title: EHS Advisor Phone Number: 435-241-9624

Injured Employers Information

Company Name: Purple Innovations Total Number of Employees in the State of Utah:
Mailing Address: 441 S Sheep Lane City: Grantsville State: UT ZIP Code: 84029
Phone Number: Same Fax Number:
Federal Employer Identification Number (FEIN): SIC: NAICS: 541715

Site Information
Site Address of Accident: Same City: State: UT Zip Code:
GPS Coordinates:
Site Contact Person: Same Contact Person(s) Title: Phone Number:

Accident Information
Date Accident Occurred: Thursday, February 4, 2021 Time Accident Occurred: 4:30 a.m. Total Number of Employee Injured: 1

Injury Additional Notes

Name(s) of Injured Age Type(s) of Injuries Body Part(s) Event Type
Classification Regarding Injury
Non-
70 Fracture(s) R b(s) Slip/Trip/Fall
Hospitalized

How did the Injuries Occur: [include pertinent details i.e. equipment involved, process, etc.]
Ee is a production worker. Ee was leaning over the table, her feet slipped out from under her, she hit the table sustaining a fractured r b.

Were There Any Witnesses: N/A Who:

Is the Equipment and/or Site being Held: N/A Pictures Taken: No

What Hospital(s) and/or Clinic(s) were Injured Employees transported to and how were they transported:
It was at the end of her shift, ee went home, was experiencing pain, went to the clinic where the fracture was diagnosed.

Other Comments

Email address for . Employer was notified of the fracture at 5:00 p.m. on 2/4/21.

Investigation, Accident Classification, & Assignment Information

Type of Investigation: Internally By Company

Overall Accident Information Classification for Reports

Investigation Classification Employer Type Event Type Type(s) of Injury Body Part(s)
Non-Fatal Accident General Industry Slip/Trip/Fall Fracture(s) R b(s)

Assignment Information if Investigated by UOSH

CSHO(s) Assigned:

Date Assigned: Time Assigned: Projected Opening Conference Date: