Formato de Informacin y Anlisis de Accidente / Incidente

Fecha de la investigacin:_________________________ N de accidente:____________________________

Incapacitante:________Leve__________Daos a la propiedad__________Incidente___________ Fatal ______
Nombre: ___________________________________________Departamento:_______________________________
Lugar del accidente/incidente:___________________________Compaa:__________________________________
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Edad:__________________________
Puesto: ___________________________________
Sexo:__________________________
Edo. Civil _________________________________
Turno:_________________________
Antigedad en el puesto: ______________________
Hora:__________________________
Antigedad en la empresa:_____________________
Fecha:_________________________
N IMSS:___________________________________
Incidente: ______

Lesin:______

Tipo de lesin:
Primeros Auxilios (FAC):______
Caso con das de trabajos restringidos (RWC):_________

Caso de tratamiento mdico (MTC): ______

Casos con das de trabajo perdidos (LWC): ________

Herida _____Cortante______Contusa______Machucamiento_______Herida mixta______Contusa cortante______

Punzo cortante______Exposicin______Qumicos______Termicos______Elctricos______Fractura______
Expuesta______Cerrada______Luxacin______Abierta______Escorlacion______Esguince______Inhalcion_____
Ingestin_______Otras_______
PARTE DEL CUERPO AFECTADA
Cabeza_____Oidos______Ojos_____Tronco______Espalda______Abdomen______Cintura______Hombros______
Extremo superior______Barazo_____Mano_____Dedos______Extremo inferior______Glteo______Genitales____
Pierna_____Pie____Dedos_____

DESCRIPCIN DEL EVENTO

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CAUSAS

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HALLAZGOS DE LA INVESTIGACION

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MEDIDAS CORRECTIVAS

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NOMBRE Y FIRMA
INFRACTOR

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NOMBRE Y FIRMA
SUPERVISOR

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NOMBRE Y FIRMA
RESIDENTE

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NOMBRE Y FIRMA
AUDITOR

NOMBRE

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TESTIGOS
PUESTO

FIRMA