Registration Number: ………………………..…………… INFORMATION SHEET ON INJURY Without inability to work or inability to work not longer than 3 calendar days) 1. Name and surname: 2. UČO ^1): Fill out the following data if the affected person is not the employee of Masaryk University Company Identification No.: Name of the employer of the affected person and its registered office (address): Address of the affected person: 3. Date and time of accident: 4. Place of accident: 5. Type of injury ^2): 6. Injured part of body ^3): 7. Total number of injured persons: 8. Shift beginning: 9. Number of hours worked immediately prior to the accident: 10. Activity during which the accident occurred: 11. Description of an accident, detailed description of the place, the causes and the circumstances under which the accident occurred: (If necessary, attach an additional sheet.) 12. What was the cause (source) of injury? ☐ means of transport ☐ portable or mobile machinery ☐ material, loads, objects (falling, slamming, falling off, impact, burying) ☐ fall on a plane, from a height, into the depth, fall through ☐ instrument, apparatus, tools ☐ electrical energy ☐ industrial pollutants, chemicals, biological agents ☐ hot substances and objects, fire and explosives ☐ stable machinery ☐ humans, animals or natural phenomena ☐ other unspecified cause 13. Why did the accident happen? ☐ failure or faulty status of one of the sources of accident ☐ poor or inadequate risk assessment by the employer ☐ defects in the workplace ☐ lack of employee´s personal protection including ☐ personal protective means ☐ breach of regulations related to work or to the instructions of the injured employee´s employer ☐ the unpredictable risk at work or human error ☐ other unspecified reason Date Name and surname Signature Employee affected by the accident: Witnesses: On behalf of the employer recorded by: Position: Notice: ^1) in case of an employee of other employer give the date of birth ^2) a ^3) fill out according to the Table 1 given on the other side of this form. The filled out form shall be given to the Industrial safety officer in the relevant part of MU or to other person responsible for record keeping of accidents at work. Table 1: CLASSIFICATION FOR injured body part CLASSIFICATION FOR TYPE OF INJURY CODE TYPE OF INJURY CODE INJURED BODY PART 0 Unknown or unspecified type of injury 0 The injured body part, unspecified 10 Wounds and superficial injuries 10 Head without detailed distinction, further unspecified 11 Superficial injuries 11 Head, brain, cranial nerves and blood vessels 12 Open wounds 12 Face 19 Other types of wounds, and superficial wounds 13 Eye 20 bone fractures 14 Ear 21 Closed fractures 15 Teeth 22 Open fractures 18 Head - more affected areas 29 Other types of bone fractures 19 Head - other parts not mentioned above 30 Dislocations, sprains, strains 20 Neck and spine, including the cervical vertebrae 31 Dislocation or incomplete dislocation 21 Neck and spine, including the cervical vertebrae 32 Sprain or strain 29 Neck - other unspecified parts 39 Other types of dislocations, sprains, strains 30 Back including the spine and back vertebrae 40 Traumatic amputation (loss of body parts) 31 Back including the spine and back vertebrae 50 Concussion and internal injuries 39 Back – other unspecified parts 51 Concussion and intracranial injuries 40 Trunk and organs without detailed resolution 52 Internal injuries 41 Chest, ribs including joints and shoulder blades 59 Other types of concussion and internal injuries 42 Chest area including organs 60 Burns, scalds and frostbite 43 Pelvic and abdominal area including organs 61 Burns and scalds (thermal) 48 Trunk – more affected areas 62 Chemical burns (acid burns) 49 Trunk – other parts not given above 63 Frostbites 50 Upper limbs without detailed resolution 69 Other types of burns, scalds and frostbite 51 Arm and shoulder joints 70 Poisoning and infections 52 Arm including the elbow 71 Acute poisoning 53 Arm from the wrist down 72 Acute infections 54 Finger 79 Other types of poisoning and infections 55 Wrist 80 Drowning and suffocation 58 Upper limbs – more affected areas 81 Suffocation 59 Upper limbs – other parts unspecified above 82 Non-fatal drowning 60 Lower limbs without detailed distinction 89 Other types of drowning and suffocation 61 Hips, hip joints 90 Effects of sound, vibration and pressure 62 Foot including knee 91 Acute hearing loss 63 Ankle 92 Effects of pressure (barotrauma) 64 Foot from ankle down 99 Other effects of sound, vibration and pressure 65 Toe 100 Effects of extreme temperature, light and radiation 68 Lower limbs – more affected areas 101 Sunburn from heat and sunlight 69 Lower limbs – other parts unspecified above 102 Effects of radiation (non-thermal) 70 Whole body and more areas without detailed resolution 103 Effects of reduced temperature 71 The entire body (systemic effects) 109 Other effects of temperature extremes, light and radiation 78 Body – more affected areas 110 Shock 79 The body - other injured body part not listed above 111 Shocks after aggression and threats 112 Traumatic shocks 119 Other types of shock 120 Multiple injury 999 Other specific injuries not included in other categories Notice (completion):