Form No : SAF/2/001

INCIDENT / INJURY OCCURRENCE REPORT Date Prepared : 29 / 09 / 08

Revision: 00

Part A:
Incident Type: Safety Environment
Incident Category : Nearmiss Fire Operational Upset
Injury Traffic Liquid / Vapor Release
Date of Incident : Time of Incident : Hours
Title :
Unit / Area of Incident : PFL Contractor

This section to be filled in case of an injury only Injury to : PFL Contractor (Tick whichever is applicable)

Name of Injured : P/No. Occupation / Trade :

Employee’s Section / Department :
Injury Classification :
First Aid Medical Treatment Restricted Work Case LWI Fatality

Cause of Injury Type of Injury

(To be filled in by Line Supervisor) (To be filled in by Safety Unit on report from Doctor)
Stuck By / Against Vehicle Accident Abrasion Cut
Over Exertion Process Upset Amputation Crush
Contact with Electricity Mechanical Failure Bruising Dislocation
Exposure to Extreme Temp. Fire / Explosion Burn – Wet Fracture
Slip / Trip / Fall from Height Gassing Burn – Dry Poisoning
Slip / Trip / Fall on Level Contact with Chemicals Burn – Chemical Sprain / Strain
Caught in / under / between Others Concussion Other
Description / Details of Incident : (this column to be filled by the supervisor in whose area the incident has occurred. )

Actions Taken :

Date of occurrence of Incident :

Reasons for sending the report late (if
applicable)
Report B will be due on (Based on 7 working days)

NAME : SIGNED DATE

UM/In-charge/Shift Engr/Area Engr/ Supervisor

Note: This initial report should reach the Safety Unit within one working day of the incident