Doc No.

KH SHOES Doc. Rev No.

Doc. Rev Date
INCIDENT/NEAR MISS INVESTIGATION REPORT Page No.
Logo 01 of 01
Incident No A-Incident with Injury B C
1 Type of Incident - Tick Wherever applicable Non Reportable (minor) Reportable (major) Near Miss Environment
2 Name of injured person
3 Status of person (Contractor / Employee)
4 Department of the injured person
5 Shift
6 Age of injured
7 Date of incident
8 Time of incident
9 Time of employee return to duty
10 Location of the incident
11 Line Supervsior Name
12 Department Head Name
13 Part of Body involved
14 Type of Injury (Minor or Major)
15 Name of Equipment/Process involved
16 Name of hospital referred if any
17 Briefly describe how the incident occurred
Attach Photos /evidence

FACTORS CONTRIBUTED TO THE INCIDENT/NEAR MISS

1 No written work Procedure / Instruction/Work Permit 12 Inadequate space
2 Lack of Equipment. 13 Inadequate storage
3 Equipment design faulty. 14 Incorrect method used.
4 Equipment fault / Failed. 15 Outdated method
5 Inappropriate equipment used 16 Inadequate ventillation/ lighting
6 Unsuitable work area 17 Excessive work load
7 Possible lack of attention 18 Lack of Personal Protective Equipment.
8 Lack of Maintenance 19 Poor Access
9 No training provided. 20 Freak Incident
10 Needs on-going training 21 Ignorance
11 Inadequate training provided 22 Others (please specify)
ACTION / RECOMMENDATIONS TO PREVENT RECURRENCE OF THIS INCIDENT/NEAR MISS

S.No. Actions/ Recommendations Responsibility Target Date Status

Effectiveness of Implementation

Comments:
HOD Head HR Safety Offcier

Signature

Date

Distribute Original of the report to Safety Offcier and Photo Copy to Department representative