Contractor: LOW SEVERITY/POTENTIAL

Contract Number: INVESTIGATION REPORT

Contract Holder:
DATE OF INCIDENT:
LOCATION OF INCIDENT:
INCIDENT SEVERITY:
(Tick on appropriate box)
Incident Actual Severity:
0 1 2 3
Incident Risk Potential:
Low Low Medium
TYPE OF INCIDENT: (Tick on appropriate box)
PERSONAL INJURY
NEAR MISS
BRIEF DESCRIPTION OF INCIDENT:
TIME OF INCIDENT:
Legend of Incident Severity:
0: No injury or damage to asset
1: Slight injury, FAC or asset damage<US$10K
4 5 2: Minor injury(MTC/RWC) or asset damage US$10K-100K
3: Major injury(LTI,PPD) or asset damage US$100K-1M
High 4: Up to 3 Fatality or PTD or asset damage US$1M-10M
5: More than 3 fatality of PTD or asset damage over US$10M
ASSET DAMAGE ENVIRONMENT POLLUTION ROAD TRAFFIC
NON ACCIDENTAL DEATH OTHERS(Specify):

PARTIES INVOLVED IN INCIDENT: COMPANY/

NAME JOB DEPARTMENT INJURY SUSTAINED

POLLUTION, ASSET LOSS OR DAMAGE:

TYPE OF FACILITY OR EQUIPMENT EQPT. TAG NO. DESCRIPTION OF DAMAGE/POLLUTION

ACTION TAKEN FOR INJURED PERSONS:

First Aid Medical Treatment Hospital Confinement

Others (Specify):_____________________________________________________________________________

IMMEDIATE CAUSE (UNSAFE ACT /CONDITION) CONTRIBUTING TO THE INCIDENT

REPORTED BY(SUPERVISOR/MANAGER):

NAME: SIGNATURE: DATE/TIME:

FIM NUMBER
UNDERLYING CAUSE (S): (ABSENCE OR LAPSE IN MANAGEMENT CONTROLS)

RESPONSIBLE TARGET
CORRECTIVE ACTION (S) TYPE
PARTY DATE
PEOPLE
PLANT/EQPT
PROCESS
1) Eliminate 2) Substitute 3) Isolation 4) Engineering 5) Supervision 6) PPE

Comments from HSE Dept.:

Investigated by: Date:
Closed out date:
Remarks:
HSEM/A: SIGNATURE: DATE: