MEMBER PERSONAL DETAILS

Name:_____________________________ JOB title:______________ Process Assigned:____________

Address:___________________________ Years Exp:____________ Years with Coop:____________
Age:______Gender:_________ Civil Status:_________ #of dependent:_______
WORK SHIFT:
INITIAL ACCIDENT/ INCEDENT REPORT
CLIENT:___________________________ ADDRESS:________________________________

REPORT DATE:_______________ # OF MEMBERS MALE:____ FEMALE:______ TOTAL:________

TIME OF INJURY:_____________ MEMBERS DAILY WAGE:__________ DATE OF INJURY:_____________

NATURE OF INJURY OR ILLNESS
Burns Amputation Suffocation Eye Irritation Fracture
Bruise Cuts / Wounds Sprain Hypertension
Others please specify:__________________
TYPE OF ACCIDENT
Fall Struck Against Caught Between Lifted / Lowered Struck By
Pushed / Pulled Trip / Slip Crushed Against Crushed By
Others please specify:__________________
SEVERITYOF INJURY
First Aid:_____ Medical:____ Fatal:____
No. of Days Lost______ Time lost on the day of injury: ____________
ACCIDENT DETAILS
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Facts and Findings:
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RECOMMENDATION:______________________________________________________________________________
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Prepared by:___________________ Checked by:____________________

Position:______________________ Position:_______________________
Sketch/Picture of the Accident and Incident

UNSAFE CONDITION
UNSAFE ACT