HEALTH, SAFETY & ENVORNMENT

HSEMS-
MANAGEMENT AT CONSTRUCTION SITE 01 0
DOCUMEN REV
Project: Ammonia Urea (OSBL)
SHEET 14 of 97

SUPPLEMENTARY INCIDENT/ ACCIDENT INVESTIGATION REPORT

TICK THE APPROPRIATE ONE AS APPLICABLE (furnished within 72 hours)
Supplementary to Incident/ Accident Report No.________(copy enclosed)

Report No.: __________________________ Date: _______________________________

Project Site: __________________________ Name of Work: ________________________
Contractor’s Name: ____________________ Contractor’s Job Engineer (Name): ________________

Non‐disabling injury (Non‐LTA) Hospitalized but resumed duty before end of 48 hrs.
Disabling Injury (Other LTA) Hospitalized & failed to resume duty within next 48 hrs.
Fatal (LTA) Death/ Expiry
First Aid Case (Non‐LTA) Resume duty after first aid

Name of the injured…………………………………………… Father’s name of the victim………………………………………...

Sub Contractor’s Name:………………………………………………………………………………….

Gate Pass No………………………. Age…………(Yrs.) Victim’s medical fitness exam (Pre‐empl) date:…………..

Date & Time of Incident/ Accident:………………………………………..

Name of Witness: 1)……………………………………. 2)………………………………………... 3)………………………………………..

Profession of victim:

Bar bender Carpenter Meson

Fitter Helper Gas cutter
Grinder Welder Electrician
Driver Rigger M/c operator
Engineer Manager Other (Specify)

Qualification

No formal education Non‐Matriculate Matriculate

Graduate Post‐graduate Other (Specify)

Job Experience

Nil Less than 2 yrs. 2‐5 yrs.

5‐10 yrs. 11‐15 yrs. 15 yrs. and above

Location where the incident happened……………………………………………………………………………………………………………….

 HEALTH, SAFETY & ENVORNMENT

HSEMS-
MANAGEMENT AT CONSTRUCTION SITE 01 0
DOCUMEN REV
Project: Ammonia Urea (OSBL)
SHEET 14 of 97

Activity/ Works that was continuing during incident/ accident: ‐

Demolition Excavation Concrete carrying

Welding Concrete pouring Scaffold erection
Mechanical transportation of Work on or adjacent to Manual transportation of
material Water Material
Piling work Scaffold dismantling Pipe fit‐ups & fabrication
Gas cutting Grinding Hydro‐testing work
Machine works Structural fabrications Work at height (>2M)
Erection activities Electrical works Other (Specify)

What exactly the victim was doing just before the incident/ accident? ...................................................................
……………………………………………………………………………………………………………………………………………………………………………..

Particulars of tools and tackles being used and condition of the same after incident/ accident:
…………………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………….
Description of incident/ accident (How the incident was caused?):
…………………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………….
Nature of injury:

Bruise or Contusion Puncture or Open wound Burn

Cut or Laceration Arm (above wrist) Sprains & strains
Inhalation of toxic or Abrasion (superficial wound) Frost bite
poisonous fumes of gases
Fracture Amputation Other (Specify)

Part of body involved in incident/ accident:

Head Ear Foot (including ankle)

Face Arm (above wrist) Toes
Eyes Fingers Leg (above ankle)
Throat Hand (including wrist) Multiple
Nostril Truck (abdomen/ Back/ Other (Specify)
chest/ shoulder)

Accident type:

Struck against Struck by Caught under

Fall on same level Caught in Contact with electricity
Fall from elevation Rubbed or abraded Toxic vapor/gas inhalation
Caught in‐between Vehicle accident Other (Specify)
Contact with (temp./ Contact with chemicals of
Extremes) Oils