EMPLOYEE INCIDENT / ACCIDENT REPORT

EMPLOYEE INFORMATION
NAME EMPLOYEE ID SOCIAL SECURITY NO.

Julieth Diaz 1007408163 ARL

JOB TITLE DEPARTMENT
Engineer Production
HOME ADDRESS HOME PHONE
Diagonal 27 g9 #77 3108975619
EMAIL ADDRESS MALE OR FEMALE DATE OF BIRTH
Julieth.diaz.990@gmail.com F
September 29 th 1999

INCIDENT DESCRIPTION
LOCATION DATE OF INCIDENT TIME OF INCIDENT
Company bathroom November 13 th 2021 1 hour
INCIDENT DESCRIPTION
In as much detail as possible, describe what caused the incident / accident / injury, what you were doing just before the
incident, and what you did after the incident. Name any objects or substances involved.

Julieth Díaz, Systems Engineer of the company, was working in her office, during the hours of rest the employee went
to the bathroom, saw a bottle of water and drank it, but did not know that the water bottle contained chlorine, she
fainted After a while an employee who was waiting her turn in the bathroom came in and saw that the engineer was on
the floor, the employee got scared and went to look for the occupational health and safety professional of the company
from whom she requested the first aid, the occupational health and safety professional recommended that she drink
plenty of water and go to the health center to which she is affiliated.

Was the employee performing regular duties at the time of incident? YES x NO

Did anyone see the employee get hurt? YES x NO

If YES, list all witnesses:

Here were some witnesses

Did the employee report this incident to anyone? x YES NO

If YES:
REPORTED TO NAME TITLE DATE REPORTED
Secretary November 13 th
Julieth Alvarado
2021
If NO, explain why you chose not to report:
INJURY DESCRIPTION
NATURE OF INJURY select all that apply
Abrasion,
Amputation Broken Bone Bruise x Burn (heat)
scrapes
Crushing
Burn (chemical) Concussion Cut, laceration, puncture
Injury
Hernia Illness Sprain, strain x Damage to body system
Other, describe:
DESCRIPTION OF INJURY PART OF BODY AFFECTED shade all that apply

Difficulty breathing (inhalation), swelling

of the throat, sore throat, pain or burning in

the nose, eyes, ears, lips or tongue, burns in

the digestive tract, abdominal pain,

vomiting.

Was first aid provided at the scene? If YES, who administered first aid?
x YES NO Juan Diego Albornoz
Please describe the first aid administered.

An attempt was made to manage calm, an attempt was made for the affected person to vomit the liquid, an attempt was

made for the affected person to drink too much water, having contact with the skin, it was recommended to wash with

plenty of water for 15 minutes, the transfer was made to the center of health to which the company is affiliated

Was medical treatment necessary? IF YES, NAME OF HOSPITAL / PHYSICIAN:

x YES NO Cosmited Ltda.
DATE OF
TIME OF VISIT HOSPITAL / PHYSICIAN PHONE
VISIT
11/13/21 1 hour 3135904304

Has the employee ever had a similar YE YE

x NO Has a similar injury been treated? x NO
injury? S S
If YES, describe previous injury If YES, where, when, and by whom were you treated?

RECOMENDATIONS TO AVOID ACCIDENTS:

List at least 5 recommendations for employees, company, 1. Once empty the containers should not be used for
cleaners, maintenance and SST cordinators and assitenats. other purposes. Use the appropiate containers for
each type of product.

2. Store chemical products in a place especially

designed for this purpose and taking into account
possible incompatibilities between them.

3. Have the original product container or label

handy if you need medical assistance.

4. Keep in a conspicuous place a directory of

emergency contacts telephone numbers.

5. Never taste chemicals or smell them for

identification.

EVIDENCES: List videos and pictures of the accident.

https://drive.google.com/file/d/1ap8VjtYyv3ogZF7lp-02pUZrM-WwYljm/view