A c c i d e n t / I n c i d e n t r e p o r t

Personal details
Name: Pravin Balki
Designation :- Operater ( TeQworth Solution and Services LLP)

Section/Dept: Mechanical Date of report: 22/11/2021

Accident/incident details
Date: 22/11/2021 Time: 03:00 P.M

Location: RC 1 ( Dry Section) Witness:

1) Rohit Urkude
2) Anurag Bhaik

Reported to whom:- Mr. Rohit Urkude ( Shift Incharge)

Full accident/incident details – what happened, or in the case of a near miss, what could have happened
As the plant was in running condition, suddenly RC-1 belt got broken down. Due to which one of piece of Raw
material fall on the head of one of the Labour Mr. Pravin Balki whose was working in RC-2 tell end cleaning
the belt. Swelling was seen on the injured area of head.

Injury – Nature of Injury :- Swelling was seen on the injured area of the head

■ Contusion/crush ■ Burn ■ Dislocation ■ Amputation

■ Laceration/open wound ■ Superficial injury ■ Foreign body ■ Internal injury
■ Concussion ■ Sprain/strain ■ Fracture ■ Dermatitis
Location of Injury
■ Head/face ■ Eye ■ Internal organs
■ Hand/fingers (Left/Right) ■ Shoulder/arms ■ Trunk (other than back)
■ Hip/leg ■ Foot/toes ■ Back
■ Other (state)
Results of accident
Lost time injury Y / N No. of days: days Workers’ compensation Y / N
Treatment received: ■ First aid ■ Doctor ■ Hospital

Remark :- He was taken to the Sugam hospital in wani. And as per instruction of Mr. Kishor Vyavhare Pravin
Balki was send for CT Scan to Allurwar hospital chandrapur