PPL HSE / FM / IIR / 01

Rev 01

INCIDENT REPORTING FORM (IR 01)

Dept. / Field / Location:

FATALITY

Area:

LTI I

RWC

ACCIDENT

NEAR MISS

(e.g. MINOR
INCIDENT /
FIRST AID)
Date of Incident:

Time:

Reported by:

Name of affected:

Employee No:

Designation:

Authorized to perform the task

Was task supervised

Incident

MPT
Non MPT

Department:

Temporary / Permanent / Contract Labor

Occurrence of

PROPERTY DAMAGE /
FIRE / DAMAGE TO
ENVIRONMENT

:
:

Not at Work

During overtime

Performing job alone

Performing job in group

YES

NO

YES

NO

Entering or leaving area / office

(Tick one)

Brief Description of Incident:

Witnesses : 1)

2)

NATURE OF INJURY

CLASSIFICATIONOF
INCIDENT

Eyes

Face / Head / Neck

Arms

Hands

Legs

Feet

Trunk

Internal

Back

Others

Design or Layout
Equipment failure
Construction Work
System of work
method of operation
Operational
conditions
Supervision
Training
Guarding
Maintenance
Fire
Explosion
Gas Leak
Oil / Chemical Spill
Others

3)
POSSIBLE CAUSE (s) OF INCIDENT

Caught in /on/between
Striking against/struck by
Motor vehicle accident
Injured while handling, lifting or carrying
Slips, Trips or falls
Overexertion/strain / position of person
Foreign Bodies/Objects
Trapped by something collapsing or overturning
Drowning or asphyxiation
Animal/Insect cases
Contact with sharps
Use of hand tools
Thermal/chemical burns
Exposure to fire
Exposure to an explosion
Contact with electricity or an electrical discharge
Workplace violence
Failure to wear PPE
Deficiency of knowledge
Personal Factors
Other kind of accidents

Treatment Provided:
Sent back to work
Referred to Site Doctor

Sent to Hospital

Sent Home

Not Applicable

Immediate Corrective actions:

Sectional Head: Name & Signature

Location Incharge: Name & Signature

Date:
Comments:

Date:

All incidents must be reported to HSE at HO within 24 hrs on IR 01.

Investigation report to be generated within 5 days on IR 03 from the date of incident.
Near Miss incidents are not required to report on IR 03, except on directives of concerned Dept. Head / Field / Location Incharge /

HSE Dept. HO based on severity and nature of incident.