 Accident / Incident Investigation Report HQ Reference No:

□ Notice of Dangerous Occurrence Report Site Reference No:

Please tick accordingly
Date:

To: Health Safety Environmental Committee

1.0 PARTICULARS OF OCCUPIER

Company’s Name:

Company’s Address:

Company’s Tel No.: Company’s Fax No.:

Site:

Please tick accordingly

Factory Registration Number Issued by MOM: □

Construction Worksite Registration Number Issued
by BCA: □
Non-Notifiable Workplace Record & Workplace
Number Issued by MOM: □

2.0 PARTICULARS OF INVOLVED/ INJURED

Part A (Add multiple Part A if there are more than one person involved)

Company’s Name:

Company’s Address:

Company’s Tel No.: Company’s Fax No.:

Trade:

Name: Age: Sex:

Address:

Nationality: Occupation:

Work Permit No.:

Expiry Date:
(Last 4 digit)

Safety Orientation Course

(SOC) Construction Expiry Date:
Certificate No.:

Notes: * Indicate NA whichever is Not Applicable, * Indicate NIL whichever is Not in List, * Do not leave any section
empty

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Part B (If required)

Was the injured worker engaged in his occupation when the accident occurred?

Is the injured is your direct employment? If not, please give name and address
of the contractor.

State the duration in which the injured is under your employment?

Name of hospital taken to/State in or out patient treatment.

State the injured is still in hospital and when he due to be discharge?

Are you satisfied that the injured has met with a bona fide accident Of
employment? If not please give details on a separate sheet.
State whether the injured has sustained any previous injury Under your
employment. If so, please give full details.

3.0 FACTS OF INCIDENT

Date of Accident/ Incident or Time of Incident/

Dangerous Occurrence: Near Miss:
Reportable to
Date of Investigation:
MOM: □Yes □ No
Incident Locality (happened where):
Part of Body Injury, State right or left
side:
Nature of work / Act:

Incident Type:

Injury or ill-health requiring first-aid only

□ Minor (includes minor cuts and bruises, irritation, ill-
health with temporary discomfort).

Injury or ill-health requiring medical treatment

(includes lacerations, burns, sprains, minor
 Moderate fractures, dermatitis and work-related upper
Severity of Incident
limb disorders).
□Yes □ No
If yes, please tick the severity
Serious injuries or life-threatening occupational
diseases (includes amputations, major
□ Major fractures, multiple injuries, occupational
cancers, acute poisoning, disabilities and
deafness).

Fatality, fatal diseases or multiple major

□ Catastrophic injuries.
Personal Protective Equipment Personal Protective
Provided: Equipment worn:

Notes: * Indicate NA whichever is Not Applicable, * Indicate NIL whichever is Not in List, * Do not leave any section
empty

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 Medical Leave Inclusive
Hospitalization (Inclusive of Sunday &
of Sunday & Public
Public Holiday):
holiday:
When did you receive notice of incident/ near miss? (specify date & time)

Was the injured under the influence of drink or drugs at the time of the incident?

State the name of any person who witnessed the incident. (If any)
Has the incident been reported to the police, Department of Industrial Safety, Ministry
of Manpower? State when and where. (If Required)
Present Rev No and
Risk-Impact Assessment Review:  Yes □ No Date:

4.0 BACKGROUND

(Brief summary of what where the activities at the worksite before the occurrence of the incident and who
assigned the job to the injured worker if any?)

5.0 DESCRIPTION OF ACCIDENT/ NEAR MISS (In point form)

(State the cause and describe the chain of events leading to the occurrence of the incident)

Notes: * Indicate NA whichever is Not Applicable, * Indicate NIL whichever is Not in List, * Do not leave any section
empty

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6.0 FINDINGS (In point form)

(Facts to be covered uniformly, reasonably and logically. State the hazardous conditions, items found at the
incident scene, dimension of the object / openings, test result conducted (if any)

7.0 CONCLUSION

(Summarize and state the factor, events and conditions that contributed to the incident)

8.0 RECOMMENDATIONS

(To prevent similar recurrence of the incident following recommendations to be implemented.)

9.0 ANNEX
(Please attach the following documents and number them.)

Notes: * Indicate NA whichever is Not Applicable, * Indicate NIL whichever is Not in List, * Do not leave any section
empty

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  Photographs of incident scene / re-enactment of incident of incident.
 Photocopy of the *injured / deceased passport / NRIC / Identification Document.
 Photocopy of the *injured / deceased Safety Orientation Course (SOC) Construction Certificate.
 Photocopy of the *injured worker’s medical certificate / deceased death certificate.
 Statement of the injured worker / witness / machinery operator.
 Photocopy of the certificates of lifting supervisor / crane operator / excavator etc. (If applicable)
 Photocopy of the personal protective equipment record.
 Photocopy of the name list of workers authorized to operate machinery and vehicles on site. (If
applicable)
 Photocopy of the certificates of crane / piling machine / passenger-cum-material hoist etc. (If
applicable)
 Photocopy of the maintenance checklists (Approved Person / Mechanic / Scaffold Supervisor etc.)
(If applicable)
 Standard work procedure for work method / PE’s design and calculation. (If applicable)
 Photocopy of the test reports of machinery and equipment. (If applicable)
 Photocopy of Form A – MOM Workmen’s Compensation Act – Notice of Accident.

Prepared By :
Date :
(Name & Signature)

Operations :
Date :
(Name & Signature)

Notes: * Indicate NA whichever is Not Applicable, * Indicate NIL whichever is Not in List, * Do not leave any section
empty

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 Re-enactment

Notes: * Indicate NA whichever is Not Applicable, * Indicate NIL whichever is Not in List, * Do not leave any section
empty

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