INCIDENT / ACCIDENT REPORT

Sl No.

Date of Incident / Accident: Date of Reporting:

Name, employee
number and
designation of the
i.
person / persons
involved in the Incident
/ Accident
Place of Incident /
ii.
Accident

Details of Incident /
iii.
Accident

Details of Injury to the

person / persons
iv.
involved in the Incident
/ Accident

Details of Material
v. Wastage or damage to
Machinery

Witness 1:
Signature of Witness &
vi. Witness 2:
Supervisor
Supervisor:

vii. Corrective Action

Copy 1: Management, Copy 2: Safety File, Copy 3: MR File

 INCIDENT / ACCIDENT REPORT

viii. Preventive Action

Signature of authorized person:

Learnings
Date:

Signatures:

Note:
1. Incident / Accident report to be completed within 24h of its occurrence
2. Attach copy of medical practitioner’s observations if applicable
3. Attach the estimate of material wasted and machinery repair charges
4. Mention the kind of fire extinguisher used in case of fire
5. Copy of this report to be forwarded to Management without fail
6. Learnings to be filled on the day of Safety Meeting

Copy 1: Management, Copy 2: Safety File, Copy 3: MR File