INCIDENT REPORT

Month / Year :
Type of Incident Nature of Incident (Near Miss/Minor Injury/
(IOD, Ex-Gratia) Major Injury/Fatal/Property Loss/Danger
Occurrence
Date of Occurrence Time of Occurrence
Hours and shift at which
incident taken place Location of Incident

Name of Injured Person E. Code Age/Sex

Depar Part of body injured Job function

tment
Section In charge Contractor Name

Description

Immediate Action Taken

Rout cause of incident

Preventive action for the recurrence

Name & Signature of Supervisor Name & Signature of Area in-charge