Adamson University

College of Engineering
Chemical Engineering Department

Accident Investigation Report

Part 1 : Identification Information

Accident /Incident No. Date of Accident: Time of Incident:

Employee's Name:

Job Title/Position: Department:

Specific Location Where Incident Occurred:

Affected Employee's Position: Supervisor:

Part 2 : Accident Information

Type of Incident:
Minor: Major:
Describe how the event occurred:

Summary of Incident:

Statement Date: Statement Time:

1) Affected Employee's Statement

Is statement for recording? Yes No

2) Supervisor Statement
 Is statement for recording? Yes No

Part 3 : Accident Analysis

1) What Happened to cause to Accident?

2) Went Wrong to Result in the Accident

Personal Protective Equipment

Human Related Equipment Related (PPE)

Physically not able to do work Equipment defective Improper PPE

Fatigue Installation failure PPE Failure

Not following instruction/procedure

Improper used of Equipment PPE Not Fit For Task

Work not related Program error Not wearing PPE

Safety Procedure Not FollowedOthers Others

Not Paying Attention

Task was to difficult to execute

Personnel Factors
Management Factors
3) Where there any Witnesses?

What part of employee's workday?

Poor Communication Relating to Duty Expections Lack of Skills

Training not provided Lack of Knowledge

Name of Witness(if any) Contact Information Statement Taken
Safety Inspection not provided
Inability to perform the task

Lack of Preventive Maintenance Under the Influence of Prohibited Drugs

Not Observing Possible Hazards Under the Influence of Alcohol

 Not Observing Possible Hazards Under the Influence of Alcohol

Poor Safety Implementation Others

Others

Part 4 : Accident Analysis - Witness Statement

Witness Name: Statement Date & Time:

Statement Taken by:

Entering or Leaving work

Breaktime Working Overtime

Work Hours Lunch/Dinner Time Others:

Yes No

Yes No
Is statement for recording? Yes No
Yes No
Witness Name: Statement Date & Time:
Statement Taken
Yes by: No

Is statement for recording? Yes No

Witness Name: Statement Date & Time:

Statement Taken by:
 Is statement for recording? Yes No

Part 5: Corrective Actions

Action # 1:

Action # 2:

Action # 3:

Action # 1 Responsible Person(s): Date Assigned: Target Date:

Action # 2 Responsible Person(s): Date Assigned: Target Date:

Action # 3 Responsible Person(s): Date Assigned: Target Date:

 Adamson University
College of Engineering
Chemical Engineering Department

Application Form
Personal Identification

Full Name: ,
(Surname) (First Name) (Middle Name)

Age: Birthday: (mm/dd/yy) Birthplace: Gender:

Address:
Street Address Barangay City/Province

Contact No: Nationality: Email Address:

Applying for Position: Fresh Graduate Yes No

Education
School Name Location Year Attended Degree Received Major

Others, licensed held? Yes No

Seminars Attended Location Year Topic

Member of Organization? Yes No

If yes, name of the organization:
Position Held: Years of Service:

Employment
Company Location Position Held Year of Service
 Job Description
Can execute basic security functions (perimeter and access control, identification procedures, patrolling, secure assets/property
etc.

Able to efficiently coordinate movements and logistics to support the client's itinerary

Can execute proactive measures to insure the safety of the client

In-Charge for monitoring and accessing hazardous and unsafe conditions

Develops measures in assuring personnel safety

Ensures that Health, Safety, Security, and Environment (HSSE) plan is prepared and implemented

Reviews and monitors Incident Action Plan for HSSE implications

Exercises his authority in case of emergencty in order to prevent or stop unsafe acts.

Conducts safety Induction/Orientation for newly hired employess and visitors

keeps employees abreast with HSSE trainings to ensure their readiness an enchance their safety acumen

Investigates accident that occur in the responsibility areas.

Ensures that sub-contractors bide with the agreed HSSE policies and procedures of the company

Assists in providing the requirements for ISO 14001:2015 and ISO 45001:2018 surveillance audit/certification

Supports in the implementation of DENR, and DOLE-OSH requirements

Performs other related tasks

Job Qualification

Candidate must possess an Engineering degree or any related 4-year course

Must have t least three (3) years related work experience

Preferably with Basic Occupational Safety & Health (BOSH) training

Being a DOLE-Cetified Safety Officer is an advantage

Good Communication (written and oral)

Strong Leadership

Pro-active nd able to work with less or minimal supervision

Computer skills

Driving skills (is advantage)

With extensive knowledge and experience in security operations

Familiarity and expertise on investigation management, security personnel administration and control

Can easily understand instructions and work under minimum supervision

Has a friendly and professional demeanour

Willing to be assigned in any area

References
Name of Person Company Position Contact No.

I hereby certify that, to the best of my knowledge, the provided information is true and accurate
Applicant's Printed Name Over Signature