ACCIDENT/ INCIDENT REPORT (Safety Concern)

1. Project Information:
Project Name: Report No. 01.
Project Location: H&S Manager Padraig Ryan

2. Select:
Accident ☐
Incident ☐

3. Information:
Date: Time:
Type: ☐ Fatality ☐ Other (Specify)
☐ Serious Injury
☐ Serious Occupational Illness/Disease
☐ Serious Dangerous Occurrence
☐ Equipment/Property Damage
☐ Major Environmental Incident
☐ Near Miss
☐ Others

Accident/ Incident
Description (Attach
additional pages if Padraig Ryan: XXXXXXXX
required):
XXXXXXXXX

Accident/ Incident
Location on
Site:
Applicable Reports: ☐ Police ☐ Medical ☐ Other
Europlan Engineering
Attached Evidence: ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

1|Page
 ACCIDENT/ INCIDENT REPORT (Safety Concern)

4. Injury Type based on Immediate Judgment of the Severity :

The actual severity and consequences of the notified based on diagnosis by licensed health care
professional and supported by medical report shall be reported in the incident investigation report.
☐ Injury causing the affected person temporarily unable to perform any regular job or restricted work
activity on a subsequent scheduled workday or shift
☐ Immediate medical treatment of the injured person(s) as an in-patient in a hospital
☐ Medical treatment of the injured person(s) within 48 hours of exposure to a substance
☐ Unknown at the time of reporting
Immediate medical treatment of the injured person(s) for:
☐ fracture ☐ the separation of skin from any underlying tissue
(such as scalping or de-gloving)
☐ loss of a distinct part or organ of body including ☐ electric shock or electrical burn
the amputation of any part of body
☐ loss of consciousness and/or requiring ☐ serious burns due to thermal and chemical agents
resuscitation
☐ a serious head injury ☐ entrapment of a body part in machinery /
equipment / plant
☐ a serious eye injury including loss of ☐ a spinal injury
sight (temporary or permanent)
☐ exposure to a hazardous material ☐ dislocation of joints
☐ penetration injury with a risk of infectious disease ☐ the loss of bodily function
transmission (such as needle-stick
☐ serious laceration ☐ other (Specify)

5. Injured Person’s Personal Details :

In case of an incident with more than one injured person, complete the information for each person using
separate forms.
Name: Occupation:

6. Equipment/Property Damage Details :

Complete.

7. Key Corrections Taken Immediately after the Incident :

Detailed Corrective Actions shall be reported in the incident investigation report.
(Attach additional pages if more space is required).
No. Actions Status
1.
2.
3.

2|Page
 ACCIDENT/ INCIDENT REPORT (Safety Concern)

Report Prepared by: Reviewed by PM (Manager In

Charge):
Name : XXXXXXX Name : Padraig Ryan
Date: Date:
Signature: Signature:

*Attached Evidence: Photographic.

3|Page