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[{
"GeneralLiabilityIncidentDetails": {
"IncidentDetails": {
"IncidentInternalID": "sample string",
"IncidentIDSystemGenerated": "sample string",
"IncidentTitleSite": "sample string",
"IncidentType": "sample string",
"LocationCode": "sample string",
"Location": "sample string"
},
"GeneralDetails": {
"WouldyouliketosubmitaGeneralLiabilityClaim": "sample string",
"GeneralLiabilityType": "sample string",
"Sub-incident TypeincidentType": "sample string",
"DateOfIncident": "2022-10-04T00:00:00.000Z",
"TimeOfIncident": "12:25",
"TimeUndetermined": "sample string",
"DayOfWeek": "sample string",
"WorkShift": "sample string",
"TimeWorkDayBegan": "sample string",
"DescriptionofIncident": "sample string",
"DateReportedtoEmployer": "2022-10-27T00:00:00.000Z",
"TimeReportedtoEmployer": "-",
"WasAssetinvolved": "sample string",
"Assets": [{
"sample string 2"
}],
"Significance": "sample string"
},
"PersonDetails": [{
"Wereindividualsinvolvedintheincident": "sample string",
"Numberofinvolvedindividuals": "sample string",
"Name": "sample string",
"Gender": "sample string",
"DateOfBirth": "sample string",
"HomeAddress": "sample string",
"City": "sample string",
"State": "sample string",
"Zip": "sample string",
"PhoneNumber": "sample string",
"Whatwaspersondoingbeforeincident": "sample string",
"Wasindividualinjuredintheincident": "sample string",
"DidInjuryresultinaFatality": "sample string",
"ResultofIncident": "sample string",
"CauseofIncident": "sample string",
"InjuredBodyPart": "sample string",
"Pleasedescribepersonsinjury": "sample string",
"Waspersonconsideredminor": "sample string",
"Pleaseprovideparentsname": "sample string",
"Pleaseprovideparentsphonenumber": "sample string",
"Takenfromsceneviaambulance": "sample string",
"Whatshoeswasclaimantwearing": "sample string",
"Wasclaimantstruckbyobject": "sample string",
"Ifstruckbyobjectwhatobject": "sample string",
"Didthepersonrefusetreatment": "sample string",
"IfYesexplainwhy": "sample string",
"Wastreatmentprovided": "sample string",
"DidthepersonsignthemedicalreleaseformIfyesplease attachDidthepersonsignthemedicalreleaseformIfyespleaseattach": "sample string",
"WereEmergencyServicescalled?": "sample string",
}],
"EmployeeDetails": {
"PersonnelType": "sample string",
"EmployeeInvolved": "sample string",
"EmployeeId": "sample string",
"PayRateType": "sample string",
"EmployeeDepartment": "sample string",
"Contractor": "sample string",
"DoyouwanttoclassifyUnsupervisedContractEmployee": "sample string",
"TypeofClientPersonnel": "sample string",
"ClientCompany": "sample string",
"NameofContractor": "sample string",
"NameofSubContractor": "sample string"
},
"LocationOfIncident": {
"IncidentOccurredonEmployersPremises": "sample string",
"AddressofIncidentLocation": "sample string",
"City": "sample string",
"County": "sample string",
"State": "sample string",
"Zip": "sample string",
"Department": "sample string",
"PinLocation": "sample string",
"LocationoftheIncident": "sample string",
"StoreManagerName ": "sample string",
"StoreManagerPhone": "sample string",
"DistrictManagerName": "sample string",
"DistrictManagerPhone": "sample string",
"Wasanythingonfloor": "sample string",
"Floorgroundscondition": "sample string",
"Incidentoccurinsideoutside": "sample string",
"IfInsidestorewhere": "sample string",
"IfInsidestorecause": "sample string",
"IfinStockroomwhere": "sample string",
"IfOutsidestorewhere": "sample string",
"IfOutsidestorecause": "sample string",
"Istherevideooftheincident": "sample string",
"Ifvideonotobtainedwhy": "sample string",
"IfEquipnotfunctionalWhy": "sample string",
"Didtheincidentresultinanydamagetocompanyequipment": "sample string",
"Pleasedescribeequipmentanddamage": "sample string",
"Didtheincidentresultinanystructuraldamage": "sample string",
"Pleasedescribedamage": "sample string",
"Wastheincidentaresultoftheftorasecurityrelatedactivity": "sample string",
"Pleasedescribetheftorsecurityrelatedincident": "sample string",
"Isthisanassaultorrobbery": "sample string",
"Weretheresuspects": "sample string",
"Werearrestsmade": "sample string",
"Wasthereapolicereport": "sample string",
"LossPreventionreport": "sample string",
"Askthemtotakephotographs": "sample string",
"Incidentlocationdiagrammade": "sample string",
},
"ProductLiability": {
"IsthisclaimaProductLiabilityclaim": "Yes",
"ProvideNameofProduct": "sample string",
"ProvideProductCode": "sample string",
"ManufacturersName": "sample string",
"ManufacturerAddress1": "sample string",
"ManufacturerAddress2": "sample string",
"ManufacturerCity": "sample string",
"ManufacturerState": "sample string",
"ManufacturerPostalCode": "sample string",
"ManufacturerPhone": "sample string",
"Pleaseprovideadetaildescriptionoftheproduct": "sample string",
"Wasstoreadvisedtoretaintheproduct": "sample string",
"Isstoreincurrentpossessionofproduct": "sample string",
"Briefdescriptionoffactsofloss": "sample string",
"Responsibilityforroatingproduct": "sample string",
"Didalocalvendorprovidethisproduct": "sample string",
"VendorsName": "sample string",
"VendorsPhoneNumber": "sample string"
},
"MedicalInformation": {
"WasindividualsenttoHospitalClinictoreceivemedicaltreatment": "yes",
"HospitalClinicName": "sample string",
"Address": "sample string",
"City": "sample string",
"State": "sample string",
"Zip": "sample string",
"Fax": "sample string",
"ClinicDoctorName": "sample string"
},
"WitnessInformation": [{
"ArethereanyWitnessesIdentified": "Yes",
"NumberofWitnesses": 1,
"LastName": "sample string",
"FirstName": "sample string",
"MiddleName": "sample string",
"PhoneNumber": "sample string",
"Notes": "sample string"
}],
"ReportInformation": {
"ReportedBy": "sample string",
"Title": "sample string",
"PhoneNumber": "sample string",
"EmailAddress": "sample string"
},
"AdditionalIncidentInformation": {
"IncidentStatus": "sample string",
"CreatedBy": "sample string",
"CreatedDate": "2022-10-27T08:24:50.940Z",
"LastUpdatedBy": "sample string",
"LastUpdatedDate": "2022-10-27T08:24:50.940Z"
}
},
"InvestigationReport": {
"InvestigationResponsibility": {
"ResponsibleTeam": [{
"Salutation": "sample string",
"FirstName": "sample string",
"LastName": "sample string"
}],
"TargetCompletionDate": "2020-04-30T00:00:00.000Z",
"Note": null,
"NotifyImmediateSupervisor": "Y"
},
"InvestigationDetails": [],
"ContributingFactors": [{
"ContributingFactorType": "sample string",
"ContributingFactors":
[
"sample string"
],
"Comments": "sample string"
}],
"5WhyMethodology": [{
"SelectActionorConditionthatmayhavedirectlycausedincident":
[
"Computer Theft"
],
"5Whys": []
}],
"RootCauseStatement": [{
"RootcauseType": "sample string",
"RootCause":
[
"sample string"
],
"Comments": "sample string"
}],
"FinalRootCauseStatement": [{
"FinalRootCauseStatement": "sample string",
"PrimaryCountermeasure": "sample string",
"PrimaryRootCause": "sample string"
}]
},
"ActionItems": [{
"SourceID": "sample string",
"SourceTitle": "sample string",
"ActionItemTitle": "sample string",
"ActionItemCategory": "sample string",
"ActionItemType": "sample string",
"ActionItemDescription": "sample string",
"ActionItemPriority": "sample string",
"ActionItemDueDate": "2020-04-16T00:00:00.000Z",
"Owners": [
"sample string"
],
"ResponsibleDepartment": "sample string",
"CounterMeasure": "sample string",
"ApplicabletoExpansion": "sample string",
"DescriptionofActionstobeExpanded": "sample string",
"ApplicabletoEEMEPMInfo": "sample string",
"EEMEPM": "sample string",
"EEMEPMInfoSubmitted": "sample string",
"DocumentNumber": "sample string",
"AssignedBy": "sample string",
"VerificationRequired": "sample string",
"ActionItemStatus": "sample string",
"ActionTaken": "sample string",
"ActionItemCompletedBy": "sample string",
"CompletedDate": null,
"DueDateExtension": "sample string",
"RequestedDueDateExtension": null,
"ReasonforDueDateExtension": "sample string",
"DueDateExtensionRequestApproved?": "sample string",
"ReasonfornotextendingtheDueDate": "sample string"
}],
"ManagementReview": [
{
"RoleName": "sample string",
"Owner":
[
"sample string"
],
"approvalduedate": "2020-04-30T00:00:00.000Z",
"Comments": "sample string",
"CompletedByManagementReview": "sample string",
"CompletedDate": ""
},
{
"ManagementReviewStatus": "sample string"
}
]
}] |
...
JSON Field | ProcessMAP System Field | ||
IncidentID | Incident ID (System Generated) | ||
InternalIncidentID | |||
IncidentTitle | Incident Title/Site | ||
IncidentType | |||
LocationCode | Location Code | ||
Location | |||
IncidentDateWouldyouliketosubmitaGenarlLiabilityClaim | |||
GeneralLiabilityType | |||
Sub-incidentType | |||
DateOfIncident | Date of Incidentincident | ||
TimeofIncidentTimeOfIncident | Time of Incidentincident | ||
TimeUndetermined | |||
DayOfWeek | Day Of Week | ||
JobShiftWorkShift | Job Shift | ||
TimeWorkDayBegan | Time Work Day Began | ||
hasthePotentialtobeSerious | Is this a serious Incident or has the Potential to be Serious? | ||
DescriptionofIncident | Description of IncidentDescriptionofIncident | Description of Incident | |
DateReportedtoEmployer | Date Reported to Employer | ||
TimeReportedtoEmployer | Time Reported to Employer | ||
IncidentOccurredonEmployerPremises | Incident Occurred on Employer's Premises | Department | PinLocation |
AddressofIncidentLocation | Address of Incident Location | ||
City | City | ||
County | County | ||
Country | Country | ||
State | State/Province | ||
ZipCode | Postal Code/Zip Code | ||
WasAssetinvolved | Was Asset involved? | ||
Assets | Select Asset(s) | ||
DateandTimeReportedtoEmployer | Date & Time Reported to Employer | ||
ConfirmSignificancelevelofincident | Confirm Significance Level of Incident | ||
EmployeeDetails | Employee / Individual WasAssetinvolved | Was Asset involved? | |
Assets | Select Asset(s) | ||
Significance | Significance of Incident | ||
PersonDetails | Person Details | ||
WasEmployeeinvolvedintheIncident | Was an Employee / Individual involved in the Incident? | ||
PersonnelType | Personnel Type | ||
EmployeeInvolved | Employee Numberofinvolvedindividuals | No. of individual involved | |
Name | |||
Gender | |||
DateOfBirth | |||
HomeAddress | |||
City | |||
State | |||
Zip | |||
PhoneNumber | |||
Whatwaspersondoingbeforeincident | |||
Wasindividualinjuredintheincident | |||
DidInjuryresultinaFatality | |||
ResultofIncident | |||
CauseofIncident | |||
InjuredBodyPart | |||
Pleasedescribepersoninjury | |||
Waspersonconsideredminor | |||
Pleaseprovideparentsname | |||
Pleaseprovideparentsphonenumber | |||
Takenfromsceneviaambulance | |||
Whatshoeswasclaimantwearing | |||
Wasclaimantstruckbyobject | |||
Ifstruckbyobjectwhatobject | |||
Didthepersonrefusetreatment | |||
IfYesexplainwhy | |||
Wastreatmentprovided | |||
DidthepersonsignthemedicalreleaseformIfyespleaseattach | |||
WereEmergencyServicescalled | |||
EmployeeDetails | Employee / Individual Details | ||
PersonnelType | Personnel Type | ||
EmployeeInvolved | Employee / Individual Involved( Last, First, M.I.) | ||
EmployeeId | Employee Id | ||
PayRateType | Pay Rate Type | ||
EmployeeDepartment | Employee / Individual Department | ||
Contractor | Contractor | ||
DoyouwanttoclassifyUnsupervisedContractEmployee | Do you want to further classify Unsupervised Contract Employee | ||
TypeofClientPersonnel | Type of Client Personnel | ||
ClientCompany | Client Company | ||
NameofContractor | Name of Contractor | ||
NameofSubContractor | Name of SubContractor | WasMachineinvolved | MachineNumber |
ReviewedbyEHSRepresentative | ReviewDateLocationOfIncident | Location of Incident | |
IncidentOccurredonEmployersPremises | |||
AddressofIncidentLocation | |||
City | |||
Country | |||
State | |||
Zip | |||
Department | |||
PinLocation | |||
LocationoftheIncident | |||
StoreManagerName | |||
StoreManagerPhone | |||
DistrictManagerName | |||
DistrictManagerPhoneWasanythingonfloor | |||
Floorgroundscondition | |||
Incidentoccurinsideoutside | |||
Ifinsidestorewhere | |||
IfInsidestorecause | |||
IfinStockroomwhere | |||
IfOutsidestorewhere | |||
IfOutsidestorecause | |||
Istherevideooftheincident | |||
Ifvideonotobtainedwhy | |||
IfEquipnotfunctionalwhy | |||
Didtheincidentresultinanydamagetocompanyequipment | |||
Pleasedescribeequipmentanddamage | |||
Didtheincidentresultinanystructuraldamage | |||
Pleasedescribedamage | |||
Wastheincidentareresultoftheftorasecurityrelatedactivity | |||
Pleasedescribetheftorsecurityrelatedincident | |||
Isthisanassaultorrobbery | |||
Weretheresuspects | |||
Werearrestsuspects | |||
Wastheapolicereport | |||
LossPreventionreport | |||
Askthemtotakephotographs | |||
Incidentlocationdiagrammade | |||
ProductLiability | |||
PropertyDamageIncidentDetails | Property Damage Incident Details | ||
IncidentType | Incident Type | ||
IsthisachargeableIncident | Is this a chargeable Incident | ||
CauseofIncident | Cause of Incident | ||
DamageSummary | Damage Summary | ||
Wascontractorinvolvedintheincident | Was contractor involved in the incident | ||
PleaseprovideContractorDetails | Please provide Contractor Details | ||
Wasthecontractortrainedoncompanypolicies | Was the contractor trained on company policies | ||
Describeanydamagecaused | Describe any damage caused | ||
Describewhatcausedtheincidenttooccur | Describe what caused the incident to occur | ||
Describeworkactivitybeingperformedduringincident | Describe work activity being performed during incident | ||
Wastheapplicableregulatoryagencynotified | Was the applicable regulatory agency notified | ||
WitnessInformation | Witness Information | ||
ArethereanyWitnessesidentified | Are there any Witnesses identified | ||
NumberofWitnesses | Number of Witnesses | ||
LastName | LastName | ||
FirstName | FirstName | ||
MiddleName | MiddleName | ||
Notes | Notes | ||
PhoneNumber | Phone Number | ||
WitnessrealtiontoProcessMAP | Witness Relation to ProcessMAP | ||
InvestigationResponsibility | |||
Salutation | Salutation | ||
FirstName | First Name | ||
LastName | Last Name | ||
TargetCompletionDate | Target Completion Date | ||
Note | Note | ||
NotifyImmediateSupervisor | Notify Immediate Supervisor | ||
InvestigationDetails | |||
All questions | |||
ContributingFactors | |||
ContributingFactorType | Contributing Factor Type | ||
ContributingFactors | Contributing Factors | ||
Comments | Comments | ||
5WhyMethodology | |||
SelectActionorConditionthatmayhavedirectlycausedincident | Select Action or Condition that may have directly caused incident | ||
Whys | Whys | ||
RootCauseStatement | |||
RootcauseType | Root cause Type | ||
RootCause | Root Cause | ||
Comments | Comments | ||
FinalRootCauseStatement | |||
FinalRootCauseStatement | Final Root Cause Statement | ||
PrimaryCountermeasure | Primary Counter measure | ||
PrimaryRootCause | Primary Root Cause | ||
Action Items | |||
SourceID | Source ID | ||
SourceTitle | Source Title | ||
ActionItemTitle | Action Item Title | ||
ActionItemCategory | Action Item Category | ||
ActionItemType | Action Item Type | ||
RootCause | Root Cause | ||
ActionItemDescription | Action Item Description | ||
ActionItemPriority | Action Item Priority | ||
ActionItemDueDate | Action Item Due Date | ||
Owners | Owner | ||
ResponsibleDepartment | Responsible Department | ||
Countermeasure | Countermeasure | ||
ApplicabletoExpansion | Applicable to Expansion? | ||
DescriptionofActionstobeExpanded | Description of Actions to be Expanded * | ||
ApplicabletoEEMEPMInfo | Applicable to EEM/EPM Info? | ||
EEMEPM | EEM / EPM * | ||
EEMEPMInfoSubmitted | EEM/EPM Info Submitted? | ||
DocumentNumber | Document Number * | ||
AssignedBy | Assigned By | ||
Verificationrequired | Verification required | ||
VerifyUser | Verify User | ||
ApprovalStatus | Approval Status | ||
Approvers | Approvers | ||
ApprovalComment | Approval Comment | ||
ApprovalDate | Approval Date | ||
ActionItemStatus | Action Item Status | ||
ActionTaken | Action Taken | ||
ActionitemCompletedBy | Action item Completed By | ||
ActionitemCompletedDate | Action item Completed Date | ||
DueDateExtension | Due Date Extension | ||
RequestedDueDateExtension | Requested Due Date Extension | ||
ReasonforDueDateExtension | Reason for Due Date Extension | ||
DueDateExtensionRequestApproved | Due Date Extension Request Approved? | ||
ReasonfornotextendingtheDueDate. | Reason for not extending the DueDate. | ||
VerificationStatus | Verification Status | ||
VerificationPerformed | Verification Performed | ||
VerifiedBy | Verified By | ||
VerificationDate | Verification Date | ||
Comments | Comments | ||
CapitalExpenditureinvolved | Capital Expenditure involved | ||
Approximatecost | Approximate cost | ||
EstimatedBudget | Estimated Budget | ||
Additional Information | |||
IncidentStatus | |||
CreatedBy | |||
CreatedDate | |||
LastUpdatedDate | |||
LastUpdatedBy |