TM IVRCL LIMITED

Preliminary Accident Report

To be Filled Immediately by Section Incharge
We make i t happen
Project Name:

LOCATION ______________________________ REPORT NO: __________________________________

DATE:_____________________________

DETAILS OF INJURED:
Name __________________________________ S/o

Date of Birth / Age __________________________ Designation: _______________

E.No ________________________ Experience in this position (Yrs)______________

Date / Time of Accident

_________________________________________________________________________

Function carried out when the accident occurred

______________________________________________________

INJURIES SUFFERED

1) Part of body affected: _____________________________________________________________________

2) Type of injury:
___________________________________________________________________________
DESCRIPTION (Attach photos, sketches, Statements )

CAUSES

LET SAFETY PREVAIL – ALWAYS AT IVRCL

 TM IVRCL LIMITED
Preliminary Accident Report
To be Filled Immediately by Section Incharge
We make i t happen
Project Name:

REMEDIAL ACTION / RECOMMENDATIONS:

DETAILS OF WITNESS(ES)
1)_____________________________________________ 2)_____________________________________________

______________________

SECTION SUPERVISOR SITE IN CHARGE

SIGN: SIGN:

NAME: NAME:

DATE: DATE:

Distribution: Site Administration Officer / Regional Manager / HSEQ –Corporate Office

Note: Witness statements, if in regional languages, must be translated in to English

LET SAFETY PREVAIL – ALWAYS AT IVRCL