Saudi Aramco Contractor Injury Report Form*

Injured Person Information Injured Person Name Badge No./ Passport or Iqama number

Supervisor Name

Company Name

Proponent Organization Information Organization Name

Representative

Injury information Injury Classification (Check one; refer to GI 6.007 for details.) On-job Fatality Lost Time Injury Restricted Duty Injury Medical Treatment Case First Aid Injury Incident Information Incident Location

No. of Lost Days

No. of Restricted Duty Days

Injury Description (In addition, also fill in the Body Parts and Nature of Injuries on the reverse side of this form.)

Incident Date

Incident Details

* For the latest version of this form plea

Reverse Encircle the appropriate codes for both Body Parts and Nature of Injuries:
CODE 0266 0267 0268 0269 0270 0271 0272 0273 0274 0275 0276 0277 0278 0279 0280 0281 0282 0283 0284 0285 0286 0287 0288 0289 0290 0291 0292 0293 0294 0295 0296 0297 0298 0299 0300 0301 0302 0303 0304 BODY PARTS General Right, Head, Brow Right, Head, Ear Right, Head, Eye Right, Head, Head Right, Head, Mouth Right, Head, Neck Right, Head, Nose Right, Head, Teeth Right, Head, Throat Left, Head, Brow Left, Head, Ear Left, Head, Eye Left, Head, Head Left, Head, Mouth Left, Head, Neck Left, Head, Nose Left, Head, Teeth Left, Head, Throat Right, Upper Extremities, Arm Right, Upper Extremities, Elbow Right, Upper Extremities, Finger Right, Upper Extremities, Forearm Right, Upper Extremities, Hand Right, Upper Extremities, Muscle/Tendon Right, Upper Extremities, Palm Right, Upper Extremities, Thumb Right, Upper Extremities, Wrist Left, Upper Extremities, Arm Left, Upper Extremities, Elbow Left, Upper Extremities, Finger Left, Upper Extremities, Forearm Left, Upper Extremities, Hand Left, Upper Extremities, Muscle/Tendon Left, Upper Extremities, Palm Left, Upper Extremities, Thumb Left, Upper Extremities, Wrist Right, Trunk, Abdomen Right, Trunk, Back 0305 0306 0307 0308 0309 0310 0311 0312 0313 0314 0315 0316 0317 0318 0319 0320 0321 0322 0323 0324 0325 0326 0327 0328 0329 0330 0331 0332 0333 0334 0335 0336 0337 0338 0339 7939 7940 7941 7942 7943 Right, Trunk, Chest Right, Trunk, Hip Right, Trunk, Rib Right, Trunk, Waist Right, Trunk, Muscle Right, Trunk, Clavic Bone Right, Trunk, Groin Right, Trunk, Pelvis Right, Trunk, Shoulder Left, Trunk, Abdomen Left, Trunk, Back Left, Trunk, Chest Left, Trunk, Hip Left, Trunk, Rib Left, Trunk, Waist Left, Trunk, Muscle Left, Trunk, Clavic Bone Left, Trunk, Groin Left, Trunk, Pelvis Left, Trunk, Shoulder Right, Lower Extremities , Ankle Right, Lower Extremities , Feet Right, Lower Extremities , Knee Right, Lower Extremities , Leg Right, Lower Extremities , Toe Right, Lower Extremities , Thigh Right, Lower Extremities , Muscle/Tendon Left, Lower Extremities , Ankle Left, Lower Extremities , Feet Left, Lower Extremities , Knee Left, Lower Extremities , Leg Left, Lower Extremities , Toe Left, Lower Extremities , Thigh Left, Lower Extremities , Muscle/Tendon Others Upper Extremities, Multiple Parts Lower Extremities , Multiple Parts Trunk, Multiple Parts Right, Head, Face Left, Head, Face CODE 0340 0341 0342 0343 0344 0345 0346 0347 0348 0349 0350 0351 0352 0353 0354 0355 0356 0357 0358 0359 0360 0361 0362 0363 0364 0365 0366 0367 0368 0369 7944 7945 7946 7947 7948 7949 7950 7951 7952 7953 7954 7955 7956 NATURE OF INJURIES General Abrasion or Scratch Amputation Asphyxia, strangulation Avulsion Blister, Mechanical Burn (Chemical) Burn , Thermal Concussion Conjunctivitis Contagious Disease Contusion, Bruise, Hematoma Dermatitis Dislocation Electric Shock injury Foreign Body Fracture Hearing Impairment Heat Effects Illness Hernia Inhalation injury Injury other Laceration Multiple Injuries Needle Stick/Puncture Sliver, Splinter Radiation Effects Injury Strain, Sprain Occup. Disease other Poisoning INTERNAL INJURY (TRAUMATIC ONLY) LOSS OR FRACTURE OF TEETH INSECT, REPTILE OR ANIMAL BITE SWELLING,TENDERNESS PNEMOCONIOSES ASBESTOSIS DEGENERATIVE INFECTED INSECT, REPTILE OR ANIMAL BITE SWELLING,TENDERNESS FATAL NO DATA FATAL INTERNAL INJURY (TRAUMATIC ONLY) Rupture Twist