ACCIDENT REPORT

Project: _______________

Sr. No: ______

Date of the Accident:

Time:

Place:
DESCRIPTION OF WHAT HAPPENED/WAS OBSERVED:

What could be happen:

YES

Injury
Material Damage
Were persons involved
Plants/Equipments Involved:

Probable Causes:

Action to Prevent

Reported by

Report Compiled by

Checked & Approved by

Name:

Name:

Name:

Job Title:

Job Title:

Job Title:

Signature:

Signature:

Signature:

Date:

Date:

Date:

NO