ACCIDENT INVESTIGATION REPORT

Ref. No. : IARP_________________________________________________________

1. Date & Time of Incident: _______________________________________________

2. Type of Incident (Tick as applicable) Personal Injury Property Damage Near Miss

3. Location: _______________________________________________________________________

4. Description of Incident: (Attach sheet if required): ________________________________________

5. Potential Severity: ____________________________________________________

(Incase of Near Miss or Dangerous occurrence)

6. Property Damage Report: ______________________________________________

6.1 Plant/Equipment involved: _________________________________________

6.2 Estimated Cost: _________________________________________________

6.3 Action taken to prevent recurrence: __________________________________

7. Personal Injury Report:

(Fill in as applicable)

7.1 Detail of the injured person

7.1.1 Name: __________________________________________________

7.1.2 Age: ____________________________________________________

7.1.3 Designation: ______________________________________________

7.1.4 Nationality: _______________________________________________

7.1.5 Company Name: __________________________________________

7.2 What was the injured person doing at the time of accident?_________________________

______________________________________________________________________

7.3 What was the immediate cause of the accident (unsafe act/unsafe condition).___________

________________________________________________________________________
HSEP/F01
 7.4 How the injury occurred?_____________________________________________________

_________________________________________________________________________

7.5 Part of the Body Affected (Tick as applicable)

Head Eyes Neck Back Face

Arm Wrist Hand Finger Internal

Leg Ankle Foot Others multi. injuries

( If others then specify )_____________________.

7.6 Type of Injury :

Minor cut injury Deep cut injury Bone fracture Burnt injury

Sprain/Strain Asphyxiation Foreign body into eyes Abrasion

Electric shock Poisoning Others/Specify:

7.7 Treatment Given:__________________________________________________________

_________________________________________________________________________

7.8 Present Status of the injured:_________________________________________________

7.9 Remarks if any:_________________________________________________________

8.0 Reported By:____________________________________________________________

(Name) (Signature & Date)

_________________________________________ ___________________________________
( Representing) (Position)

9.0 Witnessed By: 1) ______________________ 2) ______________________________

HSEP/F01