MYANMAR

ACCIDENT / INCIDENT INVESTIGATION REPORT

Project Title:

Report date: Report No.:

Reported By: Occupation/Role of

reporting person

DETAILS OF THE ACCIDENT/INCIDENT

Accident/Incident type:
Minor Harm Incident
(On site First Aid treatment with no lost time)

Serious Harm Injury

(Off site medical treatment with severe/permanent injury involving lost time)

Fatality
(death as a result of accident)

Major Incident
(major failure of a structure or service i.e. property damage, service strike)

Accident/Incident Date Accident/Incident Time

Where it happened:

Description/What
Happened:
(Record all facts prior to and
including the
accident/incident, was it a
planned activity?,
describe/list material and
property damaged, etc)

Photos attached Yes No

Witness (if any) name

and contact details

Witness Statement Yes No

attached

12(0), Pyi Thu Lane Tel: +95 1 657280 to 287 UNOPS is ISO 9001 certified
7 Mile, Mayangone Township Fax: +95 1 657279
Yangon, Myanmar E-mail: mmoc@unops.org
www.unops.org
MYANMAR

DETAILS OF INJURED PERSON

Name Age

Address/Contact
Details

Occupation Employer

Status Contractor Employee Subcontractor UNOPS Employee

Visitor Public Other

Date Injury Reported To Whom Reported

Did person returned to Yes No

work the same day?

Treatment of Injury Nil On Site First Aid only Doctor Hospitalised

Details of Treatment

Were any Emergency Yes No

Services in
Attendance?

Details of Emergency
Services if in
Attendance

Injury Details
(Injury type:
cuts/abrasions, bruising,
sprain/strain, fracture,
dislocation, foreign body,
unconsciousness, other)
(Body part: ankle/foot,
legs, arm, wrist/hand,
fingers, toes, torso, back,
head, eye, ear, multiple,
other)

Date of return to work

12(0), Pyi Thu Lane Tel: +95 1 657280 to 287 UNOPS is ISO 9001 certified
7 Mile, Mayangone Township Fax: +95 1 657279
Yangon, Myanmar E-mail: mmoc@unops.org
www.unops.org
MYANMAR

ACCIDENT/INCIDENT INVESTIGATION DETAILS

Immediate cause
(What unsafe acts or
conditions caused the
event? Note contributing
factors e.g. Incorrect use
of ladder, lack of PPE)

Secondary cause
(What human,
organisational or job
factors contributed
caused the event? poor
housekeeping, incorrect
use of tool, incorrect work
method, lack of
supervision/training, lack
of hazard control etc.)

Immediate Action
Taken:

Recommended Training of personnel Improve Hazard Identification

Preventative Action:
Improve Hazard Control Increase Supervision
Improve Hazard/Risk Assessment Discus Site Safety meeting

Signature of investigator Date

Preventative Action to be
Carried Out By:
(Name and date)

Close Out:
(Agreed actions have been
completed and situation is now
satisfactory)

12(0), Pyi Thu Lane Tel: +95 1 657280 to 287 UNOPS is ISO 9001 certified
7 Mile, Mayangone Township Fax: +95 1 657279
Yangon, Myanmar E-mail: mmoc@unops.org
www.unops.org
MYANMAR

Signature of reviewer Date

12(0), Pyi Thu Lane Tel: +95 1 657280 to 287 UNOPS is ISO 9001 certified
7 Mile, Mayangone Township Fax: +95 1 657279
Yangon, Myanmar E-mail: mmoc@unops.org
www.unops.org