Doc No.

: RIPL/IMS/R/12

ACCIDENT REPORT
Date:

.Date of Accident: Time of Accident:

1. Employee who met with an accident:

2. Location of accident happens:

3. Nature of accident:

4. Date and time of reporting back to office:

5. No. of hours lost:

6. Damage cause:

7. Cost of the damage / Repairing cost / Replacement cost:

8. Correction (Immediate action initiated):

9. Root cause of the accident:

10. Corrective action:

11. Preventive action (If applicable):

12. Documents amended based on the actions taken:

13. Effectiveness monitoring of the action taken:

14. Revenue lost:

Prepared by: Maintained by: