FINAL ACCIDENT REPORT

PROJECT TITLE: PROJECT NO.:

REPORT NO.: DATE :

ACCIDENT DETAILS:

TYPE: ______________________________ LOCATION: _______________ DATE & TIME: _____________

COMPANY: DESCON SUBCONTRACTOR SUBCONTRACTOR NAME: _______________________

CLASSIFICATION: ON THE JOB OFF THE JOB

NATURE

HUMAN LOSS:
SEVERITY: ILLNESS/MEDICAL TREATMENT RWI LTI FATALITY

PROPERTY LOSS:
SEVERITY: MINOR MAJOR DISASTER

ENVIRONMENTAL LOSS:
SEVERITY: MINOR MAJOR CATASTROPHIC

DESCRIPTION:

SUPERVISOR’S STATEMENT:

NAME: SIGNATURE:

INVOLVED OR INJURED PERSON’S STATEMENT:

1. NAME: ___________________________ DEPTT/AREA: __________________ EMP.NO.:__________

STATEMENT:

SIGNATURE: ___________________
 FINAL ACCIDENT REPORT

2. NAME: ___________________________ DEPTT/AREA: __________________ EMP.NO.:__________

STATEMENT:

SIGNATURE: ____________________

3. NAME: ___________________________ DEPTT/AREA: __________________ EMP.NO.:__________

STATEMENT:

SIGNATURE: ____________________

WITNESS STATEMENT:

1. NAME: ___________________________ DEPTT/AREA: __________________ EMP.NO.:__________

STATEMENT:

SIGNATURE: ____________________

2. NAME: ___________________________ DEPTT/AREA: __________________ EMP.NO.:__________

STATEMENT:

SIGNATURE: ____________________

3. NAME: ___________________________ DEPTT/AREA: __________________ EMP.NO.:__________

STATEMENT:
 FINAL ACCIDENT REPORT

SIGNATURE: ____________________

LOSS ASSESMENT:

DIRECT IMPACT (e.g. FINANCIAL, HUMAN, TIME AND PRODUCTION):

INDIRECT IMPACT (e.g. WORKFORCE MORAL AND COMPANY IMAGE):

IMMEDIATE CORRECTIVE ACTION:

CAUSE ANALYSIS ( e.g. UNSAFE ACT AND UNSAFE CONDITION):

REMARKS BY I/C SITE HSE:

 FINAL ACCIDENT REPORT

RECOMMANDATIONS:
 FINAL ACCIDENT REPORT

INCHARGE SITE HSE PM/SM

CC : Incharge PP&A, BA Representative & Head QHSE