Fluid Technology International Pvt Ltd...

I am reporting a work related Injury Illness Damage Loss Near miss

Incident Classification Work Related Non-Work Related Off the job

Severity Level Low Medium High

Incidence Type Unsafe Act/ Serious Violation of House Keeping

Procedure

Employee Name Supervisor:

Job title Date of incidence
Location Time of Incidence
Names of witnesses (if any)
Have you informed Supervisor about this incidence YES No
Where, exactly, did it happen?

What were you doing at the time?

Were appropriate Safety PPEs in use, at the time this of YES No

incident / accident?
Were all required PPEs / Safety Equipment available at the YES No
time this of incident / accident?
Were injured person(s) taken to the Doctor / Clinic YES No
Recommendation:

Filled By Signature Report Status

Name :