Description of Accident
Injury Type:
Eyewear Specifics:
Eyewear Worn
Available, Not Worn
Incorrect Eyewear
Eyewear Failure
No eyewear worn (at all)
Eyewear failure (burn through, filter fails...)
Eyewear is Available - but NOT used
Improper eyewear fit
Improper eyewear choice (incorrect wavelength, OD...etc)
Eyewear use is not specified
Proper eyewear is used
Incident - Summary
Beam Hazards:
Non-Beam Hazards:
Specifics:
Optional Information
Name:
Address:
Phone:
Fax:
