P. O. Box: 261032, Dubai, U.A.

E
Tel: 04 2821182, Fax: 04 - 2820215

E-mail: dynatechsafety@eim.ae

ACCIDENT / INCIDENT / NEAR MISS REPORT

Contractor :
Project :
Accident

Incident

Date of Occurrence:

Near Miss

Time of Occurrence:

DETAILS OF INJURED PERSONS:

Name

Card No.

Part of the body injured

First Aid / Hospital

Treatment

DETAILS OF MACHINERY / VEHICLES INVOLVED:

Sl.No.

Details of Machinery / Vehicle

Details of Driver / Operator

1
2
3
WITNESS:
Sl.No.

Name

Card No.

Signature

1
2
DETAILS OF PROPERTY DAMAGE:

DETAILS OF EXACT LOCATION:

Page 1 of 2

Form # DSSS/S/04

P. O. Box: 261032, Dubai, U.A.E

Tel: 04 2821182, Fax: 04 - 2820215

E-mail: dynatechsafety@eim.ae

ACCIDENT / INCIDENT / NEAR MISS REPORT

BRIEF DESCRIPTION / DETAILS OF THE ACCIDENT / INCIDENT / NEAR MISS:

CONTRIBUTORY FACTORS:
Unsafe Condition : YES / NO

Unsafe Acts: YES / NO

Lack of training / Supervision : YES / NO

NO

Bad House Keeping : YES /

Environmental Condition (Wind, rain, etc..): YES / NO

State of equipment (Faulty breaks, damaged lifting gear etc..): YES / NO
Other:
CORRECTIVE/ PREVENTIVE ACTIONS:
Required: YES / NO

Form # DSSS/S/003 enclosed: YES / NO

Report Prepared By : Name:

Signature:
Date:
Manager In-charge : Name:
Signature:
Date:
Cc: Personnel Department
Govt. Authorities

(for accident/ incident only)

Department

Cc: Safety

SAFETY DEPARTMENT Investigation details / action to be taken:

Report Closed By - Name:Signature:

Date:

Attachments:
PhotographsNos.
Police Report
Other..
Cc: Manager In-charge, Personnel Department (for accident / incident only)

(Page 2 of 2)

Form # DSSS/S/04