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Template - Initial Notification Form 2018

1. This incident report documents a work-related event that occurred at a specified location and time and resulted in some level of injury, asset damage, or environmental impact. 2. It records details of the incident such as the parties involved, the immediate cause, corrective actions taken, and the level of severity. 3. The contractor is required to complete this form to notify stakeholders of the incident and ensure appropriate follow up actions are identified and implemented.

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158 views1 page

Template - Initial Notification Form 2018

1. This incident report documents a work-related event that occurred at a specified location and time and resulted in some level of injury, asset damage, or environmental impact. 2. It records details of the incident such as the parties involved, the immediate cause, corrective actions taken, and the level of severity. 3. The contractor is required to complete this form to notify stakeholders of the incident and ensure appropriate follow up actions are identified and implemented.

Uploaded by

nagul kmtc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd

Contractor: INCIDENT NOTIFICATION

Contract Number: REPORT


Contract Holder:
DATE OF INCIDENT: TIME OF INCIDENT:
LOCATION OF INCIDENT:
INCIDENT SEVERITY: Legend of Incident Severity:
(Tick on appropriate box) 0: No injury or damage to asset or to the environment (ENV)
Incident Actual Severity: 1: Slight injury, FAC or asset damage<US$10K, slight Environmental effect
0 1 2 3 4 5 2: Minor injury(MTC/RWC) or asset damage US$10K-100K, minor ENV effect
Incident Risk Potential: 3: Major injury(LTI,PPD) or asset damage US$100K-1M, moderate ENV effect
Low Medium High 4: Up to 3 Fatality or PTD or asset damage US$1M-10M, major ENV effect
5: More than 3 fatality of PTD or asset damage over US$10M, massive ENV effect
TYPE OF INCIDENT: (Tick on appropriate box)
PERSONAL INJURY ASSET DAMAGE ENVIRONMENTAL ROAD TRAFFIC
NEAR MISS NON ACCIDENTAL DEATH OTHERS (Specify):
BRIEF DESCRIPTION OF INCIDENT:

PARTIES INVOLVED IN INCIDENT: COMPANY/


NAME JOB DEPARTMENT INJURY SUSTAINED

POLLUTION, ASSET LOSS OR DAMAGE:


TYPE OF FACILITY OR EQUIPMENT EQPT. TAG NO. DESCRIPTION OF DAMAGE/POLLUTION

ACTION TAKEN FOR INJURED PERSONS:

First Aid Medical Treatment Hospital Confinement


Others (Specify):_____________________________________________________________________________

IMMEDIATE CAUSE (UNSAFE ACT /CONDITION) CONTRIBUTING TO THE INCIDENT

RESPONSIBLE
IMMEDIATE CORRECTIVE ACTIONS TAKEN TYPE DATE
PARTY
PEOPLE
PLANT/EQPT
PROCESS
1) Eliminate 2) Substitute 3) Isolation 4) Design 5) Training 6) Admin controls 7) PPE
REPORTED BY(SUPERVISOR/MANAGER):

NAME: SIGNATURE: DATE/TIME:

REPORTED TO (PDO FIRST LINE SUPERVISOR)

NAME: SIGNATURE: Ref Indicator:

PIM NUMBER
Distribution :

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