F/OHSMS/06

Investigation Report Issue No.02

Sr. No.  MIA/2022 – 0 Date 

INCIDENT DETAILS
Department Location
Date Time Shift
Type Of Incident  Fatality,
Major, Minor, First Aid, Property
Damage and Near Miss
Employee Name
Identification Card No (IC)/ No
Passport
Company Name
Position

Parts of Body Injured

Narration (To Cover Action /

Condition / How Happened)

Conclusion

Publicise On Notice Board If, Yes

Circulated In Workshop If, Yes
PROBABLE CAUSE

IMMEDIATE ACTION
Date Of
Action spelled Action By Status
Implementation

1.

PREVENTIVE ACTION
Date Of
Action Spelled Action By Status
Implementation

1.
 F/OHSMS/06
Investigation Report Issue No.02

INVESTIGATION FINDINGS
Medical Treatment Man Days Lost

Un–Safe Action Un–Safe Condition

Root Cause Equipment Involved

Attached
Pictures/Drawing
(if necessary )

Remarks Signature