ACCIDENT/INCIDENT INVESTIGATION REPORT

1 INJURY CLASSIFICATION (check one that apply)

Fire Incident Medical Treatment Case Road Traffic Incident
First Aid Lost Time Incident Fatality
2 IDENTIFYING INFORMATION
2.1 Facility Code 2.4 Section
2.2 Injury ID No.: 2.5 Facility
2.3 Near-Miss ID No.: 2.6 Location
3 INJURED EMPLOYEE DATA (leave blank if near-miss case)
3.1 Employee No. 3.4 Position:
3.2 Age: 3.5 BUPA Card No.
3.3 Name: 3.6 Nationality:
4 TREATMENT INFORMATION (leave blank if near-miss case)
4.1 Date of Treatment: 4.6 Treatment provided by:
4.2 Time of Treatment: 4.7 Physician disposition: CHECK ONE
4.3 Nature of Injury/Illness: Continue work Hospitalization
Rest at home Fatality
4.4 Treatment Given: 4.8 Restrictions:

4.5 Treatment cost: SAR

5 ACCIDENT REVIEW INFORMATION
5.1 Date of Injury/Illness: 5.2 Time:
5.3 Date of Investigation: 5.4 Time:
5.5 Equipment, Tools, Etc. Involved:(include witnesses)

5.6 Description of Incident (Immediate Cause):

6 BASIC CAUSES (check all that apply)

Lack of Knowledge Inadequate Inspection/Maintenance Prog.
Employee Placement Purchasing Inferior Equipment
Not Enforcing Safe Practices Inadequate Rewards
Design/Construction Unsafe Method
Inadequate Personal Protective Eqpt. Others: Medical Case
7 PLANNED SYSTEM IMPROVEMENT
Implementation Completion Verification of
ROOT CAUSE ACTION PLAN Responsible
Date Date Effectiveness

for LTA Cases:

Doctor

Section Head / Manager HSE Manager Plant Manager

VP Operations