Title Reads: OSHA Mechanical Power Presses Injury Form

Contact Information

Employer's Name Management Contact:

Address City

State Zip Code Phone Number:


  1. Total Number of Employees:

  2. Employee's Name

  3. Date and Time of Injury:

  4. Describe the type of Injury sustained

  5. Type of task being performed when injury was sustained

    If other, please provide description

  6. Type of clutch used on the press

    If other, please provide description

  7. Type of safeguard(s) being used

  8. If the safeguard is not described in the standard, give a complete description

  9. Cause of the accident

    If other, please provide description

  10. Type of feeding

    If other, please provide description

  11. Means used to actuate press stroke

    If other, please provide description

  12. Number of operators required for the operation

  13. Number of operators provided with controls and safeguards Response to Item 14 is voluntary **

  14. What corrective action has been taken, if any