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  • Hse Department Accident/Incident Report Form /borang Laporan Kemalangan

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    lemuel bacsa
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    This accident report form documents an incident involving an employee. It collects details about the employee, location and time of the incident, witnesses, treatment received, damage to equipment, contributing factors, corrective actions to be taken, and classification of the incident. The form is to be completed by the involved employee's supervisor or a Safety Representative and signed off by supervisors up to the General Manager to document the incident investigation.

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    9 Incident Report Form

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    This accident report form documents an incident involving an employee. It collects details about the employee, location and time of the incident, witnesses, treatment received, damage to equipment, contributing factors, corrective actions to be taken, and classification of the incident. The form is to be completed by the involved employee's supervisor or a Safety Representative and signed off by supervisors up to the General Manager to document the incident investigation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    32 views2 pages

    Hse Department Accident/Incident Report Form /borang Laporan Kemalangan

    Uploaded by

    lemuel bacsa
    This accident report form documents an incident involving an employee. It collects details about the employee, location and time of the incident, witnesses, treatment received, damage to equipment, contributing factors, corrective actions to be taken, and classification of the incident. The form is to be completed by the involved employee's supervisor or a Safety Representative and signed off by supervisors up to the General Manager to document the incident investigation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    ACCIDENT/INCIDENT REPORT FORM

    HSE DEPARTMENT SEG-HSE-F001-R0


    /Borang Laporan Kemalangan

    Report Date/Tarikh Laporan: Running No/No Laporan:

    SECTION A: TO BE COMPLETED BY PERSON INVOLVED OR BY THEIR SUPERVISORS/ SAFETY REPRESENTATIVE

    This form is to be used to report all accidents, or incident, whether an injury occurred or not, and to document the
    accident investigation by the supervisor of the person involved or Safety Representative.

    1. EMPLOYEE/PERSON INFORMATION INVOLVED IN ACCIDENT(Maklumat pekerja yang terlibat kemalangan)

    Name/Nama:

    NRIC/ No IC: Tel h/p:

    Race/Bangsa: Tel House:

    Age/Umur:

    Job Title / Jawatan: Department/bahagian:

    Employment Status/Status jawatan : Permanent/Tetap Contract/kontrak Others/lain2

    Duration Current Job/Tempoh masa perkhidmatan: tahun bulan

    2. ACCIDENT/INCIDENT INFORMATION (MAKLUMAT KEMALANGAN)

    Location of accident/incident/Lokasi kejadian:

    Date/Tarikh kemalangan: Time/Masa kemalangan :

    Witness/Saksi kemalangan (Name and Department):

    Full accident/incident details (What happen)/ Rumusan lengkap kemalangan:

    Particular of Treatment/rawatan yang diterima:


    NIL/tidak memerlukan rawatan First Aid/Peti pertolongan cemas

    Outpatient Treatment/pesakit Luar Admission to Hospital/ditahan di wad

    Medical certificate given: Yes No

    Duration MC: days


    3. DESCRIPTION OF ACCIDENT(Maklumat kemalangan)

    Damage to equipment/buildings/vehicles/machines/etc (kerosakkan barang lain):


    What was damaged/ Barang yang telah rosak:
    Extent of damage/ Barang-barang lain yang terlibat:

    Contributing Factors (if any)Faktor penyumbang:

    Corrective Action/ Pembetulan Keadaan:


    Immediate actions/ Pembetulan segera:

    What controls can be put in place to prevent this from happening again/kaedah supaya kemalangan tidak berulang:

    Who is to implement these controls/corrective action?Siapa yang akan melaksanakan tanggungjawab ini:

    Date by which action is to be taken/ tarikh untuk melaksanakan kaedah diatas:

    4. CLASSIFICATION OF ACCIDENT (tick appropriate answer)/ klafisicasi kemalangan:

    a) Nature of Injury/Bahagian Terlibat b) Part of Body Injured c) Mechanism of Accident


    Contusion/crush(hancur) Head/face(kepala/Muka) Struck against object(tersepit)
    Laceration/open wound Hand/fingers( tangan/jari) Struck by sliding, falling, flying, or other
    (Luka Terbuka) Hip/leg moving object(tersepit pada objek yang bergerak)
    Concussion(gegaran) Eye ( Mata) Motor vehicle accident(kemalangan kenderaan)
    Burn(terbakar) Shoulder/arm(bahu/lengan) Caught in/between object(tersangkut)
    Superficial injury Internal organs(organ Fall or slip on same level(terjatuh)
    (kecederaan kecil) dalaman) Fall from height(terjatuh dari tempat tinggi)
    Sprain/strain Trunk(other than back) Injured when handling, lifting, or
    Dislocation(terseliuh) carrying(terluka)
    Foreign body(terputus) Back(bahagian Belakang) Contact with extreme temperature
    Fracture(patah) Foot/toes(Kaki) Exposure to/or contact with harmful
    Amputation Other (please specify) substances/radiation(pendedahan radiasi)
    Internal Injury(Luka Dalaman) Lain-lain Exposure to explosion(pendedahan
    Dermatitis _______________________ letupan)
    Crush by moving/slicing object
    Tersepit/Terpotong
    Physical Assault
    Needle stick/needle prick injury
    Exposure to biological agent
    Insect/animal bite
    Signature and Date(tandatangan dan Tarikh)

    Investigating supervisor/: _______________________ HSE Represent: ____________________________

    HOD: _______________________ Director: ____________________________

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