SHAN FOODS LLC. ‘Makkah Mukkaramah 21955 Saudi Arabia > ACCIDENT/INCIDENT REPORT FORM Personal details Ali oro Record No:_OG Name: Occupation: Labour. Section/Dept Pacing Brocactton\, Date of report! 1 /06/ 2022 Accident/incident details Date: 1 A= 06 - 20.22 Time: Qo Date reported:19\/ ob / 20) > Location: — Pg olution witness: fA \V alsa ith on Reported to whom: Full accidentiin ao. onity_ Roum fent details - what happened, or in the case of a near miss, what could have happened Clurxin§ wsod%& Werke Feet Hike im iWoodlem Pellet Injury — Nature of Injury 2 Contusion/crush Burn 1 Dislocation Amputation 5 Laceration/open wound 5 Superficial injury 11 Foreign body AlInternal injury 3 Concussion O Sprain/strain (0 Fracture Dermatitis Location of Injury 1 Headitace Eye 17 Internal organs a.Handifingers 1 Shoulder/arms _ 13 Trunk (other than back) uo Hipleg Footltoes u Back 1 Other (state) Results of accident Lost time injury Y/ No. of days: — days Workers’ compensation Y7N Treatment received! 9 Fist aid 1s Doctor Hospital Damage to equipment/buildingsivehicles etc. What was damaged? lotbin§ dlomoSe. Extent of damage: Contributing factors What were the contributing factors (if any)? Fondo lated in walking fteo~ Corrective actions Immediate actions? Polo Make Recommendations for action lated! in Coeset fiyoor What controls can be put in place to prevent this from happening again? Aree. Markinf fot Matexik spowrhe Who is to implement these controls/corrective actions? zag tHon Jepon Date by which action is to be taken20/ 06 | 2022 Signatures a Officer: HS Rep J x Manager: i CC = Director: Investigating officer: ‘ Yon Actions completed: Natee?/1 261 20.29 Mananar