PBHS/WPC10/2016/HSE-6

INCIDENT INVESTIGATION REPORT

Pekerjaan Piasau Konkerit Sdn Bhd

INCIDENT REPORT

Property
INCIDENT TYPE: Personnel Environmental Near Miss
Damage/Loss
Incident Location :
: WEATHER
Incident Date Fine Rainy
CONDITION:
Incident Time :
Nature of Injury : Supervisor Name :
Company Name :
Name of Victim :
IC/ Passport No. : WITNESS: YES NO
Date Of Birth : 1.
Designation : 2.
3.
Attachment (if :
Yes No NA
any)

Has the victim returned to

Yes No NA
work?
If NO, state reason why.

BRIEF DESCRIPTION

EVENT NARRATIVE

CAUSES/ INVESTIGATION

CAUSE/INVESTIGATION FINDING
 PBHS/WPC10/2016/HSE-6

INCIDENT INVESTIGATION REPORT

Pekerjaan Piasau Konkerit Sdn Bhd

CORRECTIVE ACTION

RECOMMENDATION/ SUGGESTION

REVIEW MEMBER
1.
2.
3.
4.

PREPARED BY : VERIFIED BY :

SIGNATURE : SIGNATURE :

DATE : DATE :