Document Ref.

Health, Safety & Environment IBSPL-HSE-F01

Rev.No Rev. Date
Management System Procedure 0 Oct 2018
Page
Accident Notification Form 1 of 1

Report No:

Section: 1 Details of Person Making the Report

Name
Designation & Company
Contact Telephone Number
Date & Time of Report

Section: 2 Accident / Incident Details

Project / Contract Name
Type of Accident / Incident Fatality
ity Injury Fire Property Damage Road Environment
Classification of Accident/Incident Minor Moderate Serious
Location of Accident /Incident
Date of Accident / Incident Time of Accident / Incident
Name of Injured Person
and injuries if known ?
Injured Party’s Employer details.
Details of Equipment /Plant
Involved in the incident
Was PPE being worn (Circle) YES NO Hat Boots Hi-Vi

Section: 3 Brief Details of the Accident / Incident

Section: 4 List Any Remedial / Corrective Action Taken or where it is recorded.

Section: 5 Witnesses to the Accident / Incident.

Name Title / Position Company Contact Telephone

Section: 6 Construction / Project - Manager

Name Signature Company Contact Telephone

Section: 7 Site HSE Manager/Officer

Name Signature Company Report closed date