El-Seif Engineering & Contracting Co.

INCIDENT REPORT “A”

Project Number & Name: Contract No: Date: Ref. Number:

TYPE OF INCIDENT: (Tick Where Applicable)

☐ Fatality ☐ Major Injury ☐ Environmental ☐ Medical treatment Case (Hospital)

☐ RTA ☐ First Aid ☐ Other (Specify)

LOCATION OF INCIDENT :

DETAILS OF INJURED:

Name: Employee ID: Age: Contact:

Date: Time: Nationality: Trade:

DETAILS OF INJURIES: ( Tick where applicable)

☐ Head ☐ Face ☐ Back ☐ Shoulder ☐ Arms ☐ Wrist ☐ Hands ☐ Fingers

☐ Leg ☐ Knee ☐ Foot ☐ Neck ☐ Others:

Treatment Treatment
Given: ☐ None ☐ First AID ☐ Hospital
Details:
DETAILS OF FIRST AIDER:

Name: Date: Signature:

This Section Completed by:(HSE In Charge )

☐ Struck Against (Running or Bumping) ☐ Struck By (Hit By Moving Object)

☐ Fall on Same Level (Slip and Fall, Trip Over)) ☐ Equipment Failure

☐ Fall from Elevation to Lower Level ☐ Caught In (Pinch and Nip Points)

Caught Between or Under (Crushed or

☐ Amputated) ☐ Caught On (Snagged, Hung up)

Contact With (Electricity, Heat, Cold,

☐ Radiation, Caustics, Toxics, Biological, Noise) ☐ Overstress/Overexposure/Overexertion
Environmental Spillage/Damage
Others
☐ (Spillage in liters Minor <15 Moderate 15-50 ☐ (Specify)
Major >50)

DETAILS OF WITNESSES: DETAILS OF IMMEDIATE SUPERVISOR:

Name: Name:

Employer: Employer:

Trade: Trade:

Contact #: Contact #:

BRIEF DESCRIPTION OF INCIDENT:

ESEC-HSE-F-10.2
Revision Date: 20-Mar-2018 Page 1 of 2
Rev. 02
 El-Seif Engineering & Contracting Co.

INCIDENT REPORT “A”

This section is to be completed by the HSE In-charge, include subcontract supervisor where relevant

Immediate action(s) taken to control the situation:

Immediate action(s) proposed to prevent recurrence:

CAUSATION FACTORS:
Immediate Cause: Root Cause:

Was there a risk assessment / method statement for the work activity ☐ YES ☐ NO

Was the risk assessment / method statement being followed

(including PPE being worn)
☐ YES ☐ NO

Did accident result in immediate absence from Work?

*(if Yes, complete ‘Report B’ also)
☐ YES ☐ NO

Who gave the direct Instructions for the work:

Number of Days / Hours Absent from work (if known)

(Contact Injured Person’s employer to confirm whether lost time was attributed to the accident)

SIGNATURES:
Project Director / Manager Project HSE Lead

Name: Name:

Date: Date:

Signature: Signature :

*Incident Report ‘B’ Required for?

 ALL accidents involving lost time up to 3 days. RIDDOR reportable. Any Employers Liability and Public Liability incidents (e.g. Members
of public, lost time accidents, property damage, potential claims etc.)
 The Environmental Incident which is more than 50 liters (Major) of spillage.
Mandatory Attachment :
1) Photographic Evidence
2) Witness Statement
3) IP Statement (if applicable)
4) Initial Medical Assessment Sheet (if applicable)

ESEC-HSE-F-10.2
Revision Date: 20-Mar-2018 Page 2 of 2
Rev. 02