If anyone should injure/hurt themselves while participating in your space or program you must complete this form. No matter how small the injury may seem, its important to track each incident.
Date of accident and/or injury
Include day, month & year
Name of person injured
Include first and last name
Space or Program where person was injured
All Hands Active, Ann Arbor, MI
Area515, Des Moines, IA
Barrel of Makers, Newark, DE
Beaver Dam Makers, Beaver Dam, WI
BloomingLabs, Bloomington, IN
Brain Silo, Portland, OR
Bridgewire, Reno, NV
Bucketworks, Milwaukee, WI
Club Cyberia, Indianapolis, IN
CTHS, Meriden, CT
Denhac, Denver, CO
DHMN, Appleton, WI
Eugene Maker Space, Eugene, OR
Glass Act, Toledo, IN
Hacker Lab, Sacramento, CA
Hammerspace, Kansas City, MO
Heat Sync, Mesa, AZ
Institute for Exploratory Research, Wall, NJ
JaxHax, Jacksonville, FL
Jigsaw Renaissance, Seattle, WA
Make Lehigh Valley, Allentown, PA
Lansing Makers Network (LMN), Lansing, MI
LVL1, Louisville, KY
Make It Labs!, Nashua, NH
MakeLab Charleston, Charlston, SC
Maui Makers, Haiku, HI
Mojave Makers, Mojave, CA
Mothership Hackermoms, Oakland, CA
NOVA Labs, Reston, VA
OlyMEGA, Olympia, WA
Pumping Station: One, Chicago,IL
Quelab, Albuquerque, NM
RoaStellaLabs, Roanoke, VA
Sector 67, Madison, WI
Vancouver Hack Space (VHS), Vancouver, BC
Workshop88, Glen Ellyn, IL
The World's Stage, Milwaukee, WI
GEMSI, San Francisco, CA
Geeks WIthout Bounds, Seattle, WA
The Playful Magpie, Milwaukee, WI
NetLit 101, Seattle, WA
Not on the list
Accident / Injury type
Check all that apply
Wound or Damage to the body: An injury is any wound or damage to the body. Examples include: Cut, puncture, laceration, abrasion, fracture, bruise, amputation, insect bite, electrocution, or a thermal, chemical, electrical, or radiation burn.
Slip, Trip, or Fall: Sprain and strain injuries to muscles, joints, and/or connective tissues.
Skin diseases or disorders Caused by work exposure to chemicals, plants, or other substances. Examples: Contact dermatitis, eczema, or rash caused by primary irritants and sensitizers or poisonous plants; oil acne; friction blisters, chrome ulcers; inflammation of the skin.
Respiratory conditions: Breathing hazardous biological agents, chemicals, dust, gases, vapors, or fumes. Examples: Silicosis, asbestosis, pneumonitis, pharyngitis, rhinitis or acute congestion; farmer’s lung, beryllium disease, tuberculosis, occupational asthma, reactive airways dysfunction syndrome (RADS), chronic obstructive pulmonary disease (COPD), hypersensitivity pneumonitis, toxic inhalation injury, such as metal fume fever, chronic obstructive bronchitis, and other pneumoconioses.
Poisoning: Evidenced by abnormal concentrations of toxic substances in blood, other tissues, other bodily fluids, or the breath that are caused by the ingestion or absorption of toxic substances into the body. Examples: Poisoning by lead, mercury, cadmium, arsenic, or other metals; poisoning by carbon monoxide, hydrogen sulfide, or other gases; poisoning by benzene, benzol, carbon tetrachloride, or other organic solvents; poisoning by insecticide sprays, such as parathion or lead arsenate; poisoning by other chemicals, such as formaldehyde.
Hearing loss: A change in hearing threshold relative to the baseline audiogram of an average of 10 dB or more in either ear at 2000, 3000 and 4000 hertz
All other illnesses: Heatstroke, sunstroke, heat exhaustion, heat stress and other effects of environmental heat; freezing, frostbite, and other effects of exposure to low temperatures; decompression sickness; effects of ionizing radiation (isotopes, x-rays, radium); effects of nonionizing radiation (welding flash, ultra-violet rays, lasers); anthrax; bloodborne pathogenic diseases, such as AIDS, HIV, hepatitis B or hepatitis C; brucellosis; malignant or benign tumors
Where did the accident / injury occur?
Exactly where in your space / program location did it happen? Example: Loading dock North end of Bucketworks space
Describe injury or illness, parts of body affected, and object/substance that directly injured or made person ill
Example: Second degree burns on right forearm from acetylene torch
Does your space / program have at least one First Aid Kit?
Did the accident / injury require medical treatment (including First Aid)?
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