SHE INCIDENT NOTIFICATION

(Signed Due Report within 24 Hours)

PROJECT DETAILS:
Business Unit: QYLG Incident No: 05
Project Name & Site/Office
QYLG, HRDC Lugait, Misamis Oriental
Location:
Project Type: Quarry Construction Mining Others

INITIAL INCIDENT CLASSIFICATION:

Types of Incident Near Miss
Security, Community High Potential Risk Other
(HPRI)
Property Damage Type of equipment:
Mobile Plant Fixed Plant

Environmental
Level 3 Level 4 Level 5 (Very
Level 1 (Negligible) Level 2 (Minor)
(Significant) (Serious) Serious)

Injury
FAI LTI RWI MTI
Body part injured:
Head Arm & Shoulder (_) Left / (_)Right Other _______________________
Neck Wrist & Hand (_) Left / (_) Right (Please specify)
Back Foot & Leg (_) Left / (_) Right
Trunk or internal organs Whole Body or multiple sites equally injured
Lower extremities

INCIDENT DETAILS:
Location of Incident: Date & Time:
Process or Task at time of
incident:
Incident Description:
(Briefly describe what happened – facts.
Attach additional pages or photographs if At exactly
required)
Root Cause
( Briefly explain the main Failure to secure equipment during manuevering.
reason of the incident)

Insuficient Procedure Lack of Training Poor Equipment

Causal Factor (Tick only 1):
Maintenance Lack of Inspection Lack of Risk Assesment
Injured / Involved Name & ID No: Occupation & Department: Employee Type:

Preliminary information Only – Causation Factors and Lessons Learnt will be described in the Incident Alert
F-CIM-012A
Rev. 8; 01/29/2019 Page 1 of 4
 Direct Employee
Person Details:
Indirect Employee
Insert Company name below:

External Medical Treatment No Details of medical facility injured person sent to:
Required:
Yes
Property Damaged Assessment Name and Signature:
(To be filledup by Maintenance Supervisor –
Below
Above Php50k _____________________
ballpark figure only) Php50k
Immediate Actions Taken:(Describe Others (Please specify)
what immediate actions were taken – Communicate as Conduct Risk
Facilitate alcotest
include medical treatment). per protocol Assessment
Conduct Full Investigation Report High Potential Risk Incident (HPRI)
Above 50k (working w/o permit): Operating equipment without
(to be submitted within 10 days) :
(When ticked any of the boxes)
authorization
MTI Working at height (WAH) Other (please specify):
Confined space

Tandem or critical lift

Fatigue and microsleep

Proximity to overhead lines

Name of Assigned Lead
Investigator:
Lee Arthur F. San Luis

Name of Area Supervisors: Ensure to attach Supervisor’s report

Project Managers Name and
Signature:

Category:
Project Managers Comments: (accurate analysis of incidents to identify improvement opportunities)

Human error ( unsafe act)

Equipment condition ( inadequate equipment
maintenance)
Operational condition (unsafe work
environment)

TABLE 1 – SIGNIFICANT EVENT NOTIFICATION

Incident Category Individual informing Individual Informed Timing Thru
Project Manager Unit VPs/ Client Immediate Txt message
Safety & Health FAI, MTI, RWI, LTI, Fatality and Corporate SHE Manager/AVP -
HPRI Safety Officer/PCO (Site Level) Immediate Txt message
QSHE
Corporate SHE Manager/AVP -QSHE Executive Vice President/ SVP Immediate Txt message

Executive Vice President/ SVP President Within 1 Hour Txt message/Email

Email using Incident
Project Manager Unit VPs/ Client Within 24 Hours
Notification Form
Environmental Level 3 Significant, Level 4
Serious and Level 5 Very Seriousenvironmental Corporate SHE Manager/AVP - Email using Incident
Safety Officer/PCO (Site Level) Within 24 Hours
incidents QSHE Notification Form
Unit VP/ Executive Vice President/ Email using Incident
Corporate SHE Manager/AVP -QSHE Within 24 Hours
SVPs Notification Form
Project Manager Unit VPs/ Client Immediate Txt message
Corporate SHE Manager/AVP -
Safety Officer/ PCO (Site Level) Immediate Txt message
QSHE
All others (Security, Community Incidents) Corporate SHE Manager/AVP -QSHE Executive Vice President/ SVPs Immediate Txt message
Project Manager / Safety Officer/PCO (Site Corporate SHE Manager/AVP - Email using Incident
Within 24 Hours
Level) QSHE /Unit VPs Notification Form
Unit VP/ Executive Vice President/ Email using Incident
Corporate SHE Manager/AVP -QSHE Within 24 Hours
SVPs Notification Form

Preliminary information Only – Causation Factors and Lessons Learnt will be described in the Incident Alert
F-CIM-012A
Rev. 8; 01/29/2019 Page 2 of 4
ATTACHMENT 1-PHOTOGRAPH’S
Please insert relevant photographs below & attach any other relevant information to the back of this incident notification.

[Photo ) [Photo )

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Preliminary information Only – Causation Factors and Lessons Learnt will be described in the Incident Alert
F-CIM-012A
Rev. 8; 01/29/2019 Page 3 of 4
 [Photo ) [Photo )

Preliminary information Only – Causation Factors and Lessons Learnt will be described in the Incident Alert
F-CIM-012A
Rev. 8; 01/29/2019 Page 4 of 4