Supervisor’s Accident Investigation Form

1.Name of Injured Person : RAVIDASH GORE( Company trainee).

2.What part of the body was injured? Describe in detail. LEFT FORE ARM.

3.What was the nature of the injury? Describe in detail. : TEAR THE MUSCLE, its happen deeply.

4.Describe fully how the accident happened? What was employee doing prior to the event? What
equipment, tools being using?
He was using 400 ton hydraulic press. He is helping with the operator .the scrap produced
from making trimming operation due to the scrap this accident happens.

5.Names of all witnesses:

1.G HEMANTH KUMAR ( JE ) QUALITY DEPARTMENT.

2.HARIHARAN ( JE) QUALITY DEPARTMENT.
3.BALU ( JE) PRODUCTION INCHARGE

6.Date of Event :11/03/18 Time of Event: 16:30

7.Exact location of event: 400 TON SCRAP AREA

8.What caused the event?

Due to the sharp edges of the scrap.this scrap produced from reflector trimming operation.

9.Were safety regulations in place and used? If not, what was wrong?
Yes he is following all the safety regulations.

10.Employee went to doctor/hospital?

Doctor’s Name: dr CMO.
Hospital Name :SIMS (S R M INSTITUTES FOR MEDICAL SCIENCE).

11.Recommended preventive action to take in the future to prevent reoccurrence.

Clear instructions given to all operator about incident. Instructions give to all operator “ the scrap
disposal in closed bin”.

Supervisor Signature Date:

(G HEMANTH KUMAR)