FIRI-01

HAZARD / NEAR MISS / LOSS / ACCIDENT / INCIDENT INVESTIGATION REPORT Ref.#.

Project Name: SM UDANETA CENTRAL 3rd FLOOR MALL EXPANSION Date of Report:
Reported by: Safety Department Time of Report:
Location: Reviewed by:

HEALTH & SAFETY INCIDENT:

Property Damage illness Restricted work injury
Vehicle First aid injury Lost time injury
Near Miss Medical aid injury Hazard
Unsafe Act Unsafe Condition Others:
BRIEF DESCRIPTION OF HOW THE INCIDENT HAPPENED:

IMMEDIATE CORRECTIVE ACTION:

ROOT CAUSE ANALYSIS? WHY DID INCIDENT OCCUR?

CORRECTIVE ACTION: LONG TERM ACTION TO ADDRESS THE ROOT CAUSE

IMPLEMENTATION TARGET DATE: SIGNED BY:

THE CORRECTIVE ACTION WAS VERIFIED AS IMPLEMENTED AND SIGNED BY:

EFFECTIVE