Di-134 - Report Of Accident / Incident

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Form DI-134 (July 1981)
FIELD REPORT NO.
U.S. DEPARTMENT OF THE INTERIOR
Exception to SF-91A-92
Safety Management Information System
Approved by Bureau of the Budget
March 1963
DATE
REPORT OF ACCIDENT / INCIDENT
1. REPORTING UNIT AND ADDRESS
2. NAME OF PERSON INVOLVED (last, first, middle initial)
6. EMPLOYMENT
4. SEX
3. AGE
STATUS
Male
ADDRESS (include zip code)
7. OCCUPATIONAL CODE
Female
(last digit here)
5. SOCIAL SECURITY NUMBER
Use separate form for each person involved
8.
DATE AND TIME OF INCIDENT
20.
LOST TIME DATA
MO.
DAY
YR.
YR.
MO.
DAY
HR.
MIN.
9. ACTIVITY
a. Date unable to perform regularly
established duties
b. Date returned to work
10. STATE IN WHICH INCIDENT OCCURRED
(Regularly established duties)
11. TYPE OF ACCIDENT / INCIDENT
c. Date returned to work
(Restricted work activities)
12. RESULT OF ACCIDENT / INCIDENT
d. Date terminated
13. NATURE OF INJURY / ILLNESS
e. Date permanently transferred to
lighter duty
14. SEVERITY OF INJURY / ILLNESS
f. Number of days of restricted work
15. PART OF BODY AFFECTED
activity
TO BE COMPLETED BY SAFETY MANAGER ONLY
16. SOURCE (What was used, done, contacted, etc?)
g. Number of days lost (Optional)
(ANSI--Z16.4)
17. HUMAN FACTOR
h. Number of lost workdays (Required)
18. PHYSICAL / ENVIRONMENTAL FACTOR
(OSHA--29 CFR 1960.2 (I))
i. Recordable occupational injury / illness
YES
NO
YES
NO
19. REPORT SENT TO OWCP?
(OSHA--29 CFR 1960.2 (o))
23. IDENTIFICATION OF PROPERTY INVOLVED
21. PROPERTY OWNERSHIP
(name, model number, size, make, type, etc.)
AMOUNT OF PROPERTY DAMAGE
22.
a. Government:
(Dollars Only)
a. GOVERNMENT
b. OTHER
0 0
0 0
$
$
b. Other
24. NARRATIVE OF ACCIDENT / INCIDENT (Include who, what, when, where, and how)
Continue on separate sheet, if necessary
25. CORRECTIVE ACTION TAKEN OR PLANNED
WHEN: Now
Fiscal Year
Signature and title of reporting official
Initials of Bureau
Safety Manager
Signature of reviewing authority
Date
Date
This form was electronically produced by Elite Federal Forms, Inc.

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