Teamsters

North America's Strongest Union

2020 Workers' Memorial Day Workplace Fatality Report

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Please complete this report in the event of an on-the-job death, in the previous year to the present.

Date occurred _________________________

Time occurred ________________________

 

Information about Deceased:

 

Name:________________________________

Job Class/Title ________________________

Social Security Number _________________

Local Union Number ___________________

 

Information about Company:

 

Company Name ______________________________________________________________

Address _____________________________________________________________________

City _________________________________

State(Province)_________________________

Zip Code ______________

Type of Industry ______________________________________________________________

Bargaining Unit Size at company _________________________________________________

 

Reported By:

Name ______________________________________________________________________

Title _______________________________________________________________________

 

Cause of Death: (pick one)

 

 

__ Electrical

__ Inhalation of gas, specify ______________

__ Elevator/hoist conveyor

__ Stepped on

 

__ Explosive

__ Struck by:

 

__ Fall

 

__ Vehicle

__ Fire

 

__ Machine

__ Hand tool

 

__ Object

__ Handling objects, manual

 

__ Other, specify ________________

__ Heat

__ Striking against object

__ Poisoning

__ Vehicular accident:       __ Local Pickup&Delivery

__ Other, specify

 

__ Over-the-road

_______________________

 

__ Powered industrial truck

_______________________

 

__ Other, specify ________________

_______________________

__ Workplace Violence

 

 

 

       

                Notes: (Please provide details of the incident)

PLEASE MAIL OR FAX TO:
IBT Safety and Health Department
25 Louisiana Ave, NW, Washington, DC 20001
Telephone: (202) 624-6960
Fax: (202) 624-8740
 

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