| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | local engineering #(+) | 0;1 | FREE TEXT | B | Computer generated record identfier in the form YYYYNNNN where YYYY is the four digit fiscal year and NNNN is a computer generated sequential number. | |
| 1 | case number | 0;2 | FREE TEXT | C | Case number assigned by the site. | |
| 2 | report type | 0;3 | SET OF CODES | I:INITIAL S:SUPPLEMENTAL C:CORRECTED | Type of transaction being processed. | |
| 3 | result | 0;4 | SET OF CODES | P:PROPERTY ONLY I:INJURY or ILLNESS B:BOTH | Result of the accident. | |
| 4 | accident class | 0;5 | SET OF CODES | A:MOTOR VEHICLE B:LABORATORY C:OFFICE G:ASSEMBLY J:PATIENT CARE L:STORAGE M:GROUNDS N:DIETETICS Z:OTHER | Classification of accident being reported. | |
| 5 | occurrence date | 0;6 | DATE-TIME | Date of accident. | ||
| 6 | occurrence time | 0;7 | FREE TEXT | Time of accident (on a 24 hour clock). | ||
| 7 | site | 0;8 | SET OF CODES | A:ON REPORTING ACTIVITY PROPERTY B:OFF REPORTING ACTIVITY PROPERTY | Classification of accident location. | |
| 7.5 | specific location | 0;9 | FREE TEXT | Text description of location where accident happened. | ||
| 8 | tort claim | 0;10 | SET OF CODES | Y:YES, IS POSSIBLE N:NO, NOT POSSIBLE | Investigator's opinion as to whether or not legal action against the agency is likely because of this accident. | |
| 9 | last name of involved | 1;1 | FREE TEXT | D | Name of person affected by accident. | |
| 10 | first/middle initials | 1;2 | FREE TEXT | First name and middle initial of person affected by accident. | ||
| 11 | ssn | 1;3 | FREE TEXT | E | Social security number of person affected by accident. | |
| 12 | sex | 1;4 | SET OF CODES | M:MALE F:FEMALE | Sex of person affected by accident. | |
| 13 | personnel status | 1;5 | SET OF CODES | A:EMPLOYEE B:VOLUNTEER C:CONTRACTOR D:INPATIENT E:OUTPATIENT F:STUDENT G:VISITOR Z:PERSON N.E.C. | Employment status of person affected by accident at the reporting facility. | |
| 14 | age | 1;6 | NUMERIC | Age of person affected by accident at time of accident. | ||
| 15 | pay plan | 1;7 | FREE TEXT | Pay plan of person affected by accident, if said person is a government employee. | ||
| 16 | occupational code | 1;8 | FREE TEXT | Position classification (from position description). | ||
| 17 | grade | 1;9 | FREE TEXT | Civil service pay grade of person affected by accident. | ||
| 18 | home address | 2;0 | WORD-PROCESSING | Home address of person affected by accident. | ||
| 19 | home phone # | 3;1 | FREE TEXT | Home phone number (including area code) of person affected by accident. | ||
| 20 | work phone # | 3;2 | FREE TEXT | Work phone (or extension) of person affected by accident. | ||
| 21 | ca1/ca2 | 3;3 | BOOLEAN | Y:YES N:NO | Is an Office of Workmen's Compensation claim being filed? | |
| 22 | time on duty | 3;4 | FREE TEXT | Time an employee had been on duty (in hours) when accident happened. | ||
| 23 | duty status | 3;5 | SET OF CODES | A:FULL TIME EMPL ON DUTY B:TEMP EMPLOYEE ON DUTY C:PART TIME EMPL ON DUTY D:NON-PAID EMPL ON DUTY Z:STATUS N.E.C. | Official payroll status of person affected by accident. | |
| 24 | accident activity | 3;6 | POINTER | 6924.1 | Classification of accident in accordance with standardized schema. | |
| 25 | service/division # | 3;7 | POINTER | 6924.3 | Service affiliation of person affected by accident. | |
| 26 | severity of injury | 4;1 | SET OF CODES | 1:NO TREATMENT REQUIRED 2:FIRST AID ONLY 3:MEDICAL TREATMENT ONLY 4:DIAGNOSIS OF ILLNESS 5:DISABLING 8:FATALITY | Extent of injury sustained. | |
| 27 | culmination | 4;2 | SET OF CODES | 1:NO RESTRICTION 2:RESTRICTED 4:PERMANENT TRANSFER 5:TERMINATED | Outcome of accident with respect to employment status of person affected. | |
| 28 | restricted work days | 4;3 | FREE TEXT | Number of days for which person affected by accident was restricted from performance of normal duties. | ||
| 29 | lost work days | 4;4 | FREE TEXT | Number of days that person affected by accident was unable to report for work. | ||
| 30 | injury/illness nature | 4;5 | POINTER | 6924.2 | Classification of accident or illness in accordance with standardized schema. | |
| 31 | body part affected | 4;6 | SET OF CODES | 01:HEAD 16:CHEST OR ABDOMEN 45:BACK 46:SHOULDER/ARM/HAND 61:HIP/LEG/FOOT | Indicator of anatomical region most affected by accident. | |
| 32 | cause of injury | 4;7 | SET OF CODES | A:STRUCK AGAINST B:STRUCK BY D:SLIP/TRIP/FALL F:CAUGHT IN/UNDER OR BETWEEN I:ILLNESS J:OVER EXERTION K:ELECTRIC CURRENT L:EXTREME TEMPERATURE M:CHEMICALS O:RADIATION T:ASSULT X:CAUSE N.E.C. | Indicator of type of accident. | |
| 32.5 | needle stick? | 4;8 | SET OF CODES | Y:YES INJURY INVOLVED NEEDLE N:NO INJURY DID NOT INVOLVE NEEDLE | Is this accident an inadvertent skin puncture involving a hypodermic needle? | |
| 33 | property ownership | 5;1 | SET OF CODES | A:VETERANS ADMINISTRATION C:OTHER FEDERAL AGENCY H:PRIVATE L:OWNERSHIP N.E.C. | Ownership of property (if any) involved in accident. | |
| 34 | amount of damage | 5;2 | NUMERIC | Estimate of damage resulting from the accident. | ||
| 35 | property damaged | 5;3 | SET OF CODES | AA:MOTOR VEHICLE AG:OTHER VEHICLE EA:BLDG./STRUCTURE FA:EQUIPMENT GA:SUPPLIES IA:FURNITURE JA:RECORDS KA:TREES/GRASS/PLANTS BA:BEDDING/CLOTHES CA:INTERIOR FINISH HA:TRASH/RUBBISH ZA:PROPERTY N.E.C. | Type of property (if any) damaged in the accident. | |
| 36 | year manufactured | 5;4 | FREE TEXT | Last two digits of year in which damaged property (if any) was manufactured. | ||
| 37 | weather factor | 6;1 | SET OF CODES | A:SNOW/ICE B:DUST STORM C:LIGHTNING D:HIGH TEMPERATURE E:LOW TEMPERATURE F:HUMIDITY H:FOG J:RAIN N:WIND STORM P:WEATHER N.E.C. Z:WEATHER NOT A FACTOR | Weather conditions at time of accident. | |
| 38 | source of accident | 6;2 | SET OF CODES | 01AA:UNPOWERED EQUIP/FURNISHINGS/SUPPLIES 11AA:POWERED EQUIP/APPLIANCES/MACHINES 33AA:BLDG MATERIAL, FEATURE OR CONDITION 44AA:TOXIC SUBSTANCE/RADIATION EXPOSURE 77AA:VEHICLE 81AA:PERSON 82ZZ:SOURCE N.E.C. | Causative agent of damage to people and/or property. | |
| 39 | cause of accident | 6;3 | SET OF CODES | AA:EQUIPMENT OR ENVIRONMENT BA:PERSON CA:NATURE FA:CAUSE UNKNOWN | Investigator's opinion as to principal cause of accident. | |
| 40 | additional cause | 6;4 | SET OF CODES | AA:EQUIPMENT OR ENVIRONMENT BA:PERSON CA:NATURE ZZ:NO ADDITIONAL CAUSE | Secondary cause of accident. | |
| 41 | fire-form of ignition | 6;5 | SET OF CODES | 21:ELECTRICAL ARC 31:SMOKING MATERIAL (CIGARETTES,ETC) 61:SOURCE N.E.C. 71:SOURCE UNKNOWN | Means by which fire was ignited. Leave blank for other types of accidents. | |
| 42 | fire..material burned | 6;6 | SET OF CODES | 11:GAS 21:LIQUID 31:SOLID 41:LIQUID & GAS 71:SOLID & GAS 81:SOLID & LIQUID | Principal fuel for the fire. Leave blank for other types of accidents. | |
| 43 | fire..material form | 6;7 | SET OF CODES | GZ:ALL FIRES | Indicates that accident was a fire. | |
| 44 | best preventative | 6;8 | SET OF CODES | A:TRAINING B:MORE STAFF C:MOTIVATION D:BETTER EQUIPMENT/MATERIAL E:BETTER PLANNING & COORDINATION F:IMPROVED WRITTEN PROCEDURES G:MORE FUNDS FOR HAZARD ELIMINATION H:PERSONNEL ACTION I:PREVENTATIVE N.E.C. Z:NONE | Investigator's opinion as to the best safeguard against future incidents of this kind. | |
| 45 | corrective action | 6;9 | SET OF CODES | A:TAKEN B:REQUIRED & ANTICIPATED C:REQUESTED D:NONE | Status of corrective action(s) at time of this report. | |
| 46 | accident narrative | 7;0 | WORD-PROCESSING | Detailed description of the accident, including events leading up to it. | ||
| 47 | witnesses | 6;10 | FREE TEXT | Names of individuals who witnessed the accident. | ||
| 48 | corrective narration | 8;0 | WORD-PROCESSING | Detailed description of action(s) taken or planned to prevent similar incidents in the future. | ||
| 49 | initiator name | 9;1 | FREE TEXT | Name of person who initiated this report. | ||
| 50 | initiator title | 9;2 | FREE TEXT | Job title of initiator. | ||
| 51 | initiator date signed | 9;3 | DATE-TIME | Date on which accident report was signed by initiator. | ||
| 52 | initiator phone # | 9;4 | FREE TEXT | Phone number (or extension) of person who initiated this report. | ||
| 53 | review authority name | 9;5 | FREE TEXT | Name of reviewing official. | ||
| 54 | review authority title | 9;6 | FREE TEXT | Job title of reviewing official. | ||
| 55 | review authority date | 9;7 | DATE-TIME | Date on which review of accident by reviewing official was completed. | ||
| 56 | review authority phone | 9;8 | FREE TEXT | Telephone number (or extension) of reviewing official. | ||
| 57 | evaluation of report | 10;0 | WORD-PROCESSING | Reviewer's notes on the result of his/her investigation. | ||
| 57.5 | report status | 9;9 | SET OF CODES | Y:YES, 2162 REPORT COMPLETED N:NO 2162 REPORT NOT COMPLETED | Completion status of this report. |
Not Referenced