HSE INCIDENT NOTIFICATION FORM

Instructions for use:

This report must be completed by the individual sustaining injury or witnessing the event within 24 hours and
submitted to HSE department or sent to group.hseq@efsme.com
1. REPORTING PROJECT INFORMATION
Name of Project: OXAGON Pioneer Camp
Name of OPCO: KSA NEOM
Project Manager/ In charge: Hamza Sajjad

Email Address: Hamza.Sajjad@efsme.com Mobile Number: 0530391522

2. INCIDENT INFORMATION:
Date of Incident: 02-04-2024. Time (use 24 Hour Clock): 12:17 Hrs.
Others
√ Near Miss ☐ Fatality ☐ Serious Injury ☐ (List Below)
Medical Treatment Dangerous
☐ First Aid Cases ☐ Care
☐ Occurrence
√ Fire Alarm
Type of Incident
Serious
Equipment/Property Restricted work
☐ Damage
☐ case
☐ Occupational ☐
Illness/Diseases
Vehicle
☐ Environmental ☐ Fire Incident ☐ Accident
☐

OXAGON Pioneer zone B

Incident Workplace OXAGON Pioneer Camp Incident Location on Site: type cabins
There was an incident reported on 2nd April 2024 around 12:17 Hrs. where the fire
alarm activation type Smoke Detector of Block D2-4 Room-02. System is not
showing any indication of alarm. EFSIM FERS team listen the alarm and responded.

DETAILS OF THE EVENT.

The alarm Activation at 12:17 Hrs.
EFSIM FERS Team attended the scenario at 12:18 Hrs.
Incident Description: The alarm was silenced at 12:20 after identifying the cause of the alarm.
FERS Team returned to the station at 12:25 Hrs.

During the investigation, the EFSIM FERS team get to know that
Some SATCO technicians are doing paint work in D2 Section. Due to the spray paint
fumes the smoke detector activated the alarm.

Applicable Reports EFS FERS REPORT

☐ Police ☐ Medical ☐ Others (specify):
Attached:

3. INJURED PERSON’S PERSONAL DETAILS (For Injuries):

In case of an incident with more than one injured person, complete the information for each person using separate forms
No injuries were involved in accident Employer:
Name:

Date of Birth:
Employee ID:

Nationality: Years of Experience: Years Months

Designation/Occupation: Gender: ☐ Male ☐ Female

Contact Phone Number: Other Details:
(IRATA ID, IRATA Hours etc.)

Notice: A hard copy of this document may not be the document currently in effect. The current version is always on the EFS SharePoint.
Parent Doc №: HSE 200-SOP-0025 Document №: HSE 400-FRM-00025A Revision №: Version №:
Document Published Date: 06/07/2022 Last Review Date: 05/07/2022 Next Review Date: 05/07/2025 Doc Validity: 3 years
 HSE INCIDENT NOTIFICATION FORM

4. KEY ACTIONS TAKEN IMMEDIATELY/TO PREVENT RE-OCCURRENCE AFTER THE INCIDENT:

No. Actions Person Responsible Target
Date
1. Sensitized the workers to take preventive measures before doing any paint work. EFSIM FERS TEAM 02/4/2024

2. Give awareness to workers to cover the smoke detector with tap and remove the tap after EFSIM FERS TEAM 02/4/2024
completion of work.

3. Inform to the safety team to ensure that preventive measure has been taken before starting EFSIM FERS TEAM 02/4/2024
this type of work.

4.
5.
6.
7.

5. INJURY DETAILS (if applicable)

☐ Abrasions/Bruising ☐ Amputation - Traumatic ☐ Bite/sting
☐ Burn ☐ Concussion ☐ Crush/Internal Injury
☐ Cuts/Laceration/Open Wound ☐ Hearing Loss/Deafness ☐ Dislocation
Nature of Injury / ☐ Electric Shock ☐ Foreign Body under skin ☐ Fracture
Illness
☐ Foreign Body in Eye ☐ Infectious Disease ☐ Hernia
☐ Heat Related Illness ☐ Psychological (Stress) ☐ Nerve/Spinal Cord injury
☐ Musculoskeletal ☐ Poisoning/Toxic Effect –
☐ Occupational Illness / Disease
Disorder – Chronic/RSI Ingestion

Nature of Injury / ☐ Poisoning/Toxic Effect - Inhalation ☐ Strain/Sprain ☐ Respiratory Disease

Illness
☐ Skin Irritation/Disease ☐ Other
☐ Bite/Sting ☐ Biological Factors ☐ Cave-In or Collapse
☐ Chemicals/Substances/Radiation ☐ Drowning/Submersion ☐ Dust/Fumes/Gases
☐ Extreme Temperature /Fire ☐ Electricity ☐ Fall from Height
Mechanism of Injury
☐ Hit by Moving Object/Crush/Vehicle ☐ Manual Handling ☐ Mental Stress
/ Illness:
☐ Occupational Violence ☐ Penetrating Injury (needle stick, puncture wound)
☐ Repetitive Motion ☐ Slip, Trip and Fall ☐ Sound/Pressure
☐ Struck by Falling Object ☐ Other
☐ Animal/Human ☐ Confined Space ☐ Environmental Conditions
☐ Fixed Machinery Plant ☐ Infectious Agent ☐ Materials or Chemical Substances
Agency / Source of ☐ Powered Equipment/Tools/ ☐ Non-Powered ☐ Scaffolding or Ladders or Rope
Injury / Illness: Appliances Equipment/Tools Access

☐ Mobile Plant/Equipment ☐ Trench or Excavations ☐ Other

☐ Sharps/Scalpels/Needles ☐ Road Transport/Vehicles
☐ Cervical Spine ☐ Ear ☐ Face (excluding eye)
☐ Head/Neck ☐ Eye ☐ Forehead ☐ Mouth
☐ Neck ☐ Nose ☐ Scalp/Skull
☐ Abdomen ☐ Back ☐ Genitals
☐ Trunk
☐ Pelvis ☐ Spine ☐ Thorax
Body Location:
☐ Clavicle ☐ Elbow ☐ Fingers (exclude
thumb)
☐ Upper Extremity
☐ Forearm ☐ Hand ☐ Shoulder
☐ Thumb ☐ Upper Arm ☐ Wrist
☐ Lower Extremity ☐ Ankle ☐ Buttocks ☐ Foot

Notice: A hard copy of this document may not be the document currently in effect. The current version is always on the EFS SharePoint.
Parent Doc №: HSE 200-SOP-0025 Document №: HSE 400-FRM-00025A Revision №: Version №:
Document Published Date: 06/07/2022 Last Review Date: 05/07/2022 Next Review Date: 05/07/2025 Doc Validity: 3 years
 HSE INCIDENT NOTIFICATION FORM

☐ Hip/Groin ☐ Knee √ Lower Leg

☐ Thigh ☐ Toes
☐ Arteries ☐ Brain ☐ Heart
☐ Internal Organs ☐ Intestines ☐ Kidney ☐ Liver
☐ Lungs ☐ Spleen ☐ Stomach
☐ General ☐ Heat Related ☐ Occupational Illness ☐ Other
6. Incident ☐ YES √ NO
Investigation
Required
If “Yes” -Incident Investigation shall be conducted and recorded in HSE 400-FRM-0025B -Incident
Investigation Form
If “No”- Incident Notification form shall have all adequate information
7. DECLARATION

√ I declare that all information provided in this document is true, correct and complete.

HOD / MANAGER / ENGINEER / SUPERVISOR

Name: HAMZA SAJJAD Employee ID: 1065307

Signature: Signed Date: 02/4/2024

HSE REPRESENTATIVE
Name: Muhammad Sharif Employee ID: 1035490

Signature: Date 02/4/2024

Additional
Information:

Notice: A hard copy of this document may not be the document currently in effect. The current version is always on the EFS SharePoint.
Parent Doc №: HSE 200-SOP-0025 Document №: HSE 400-FRM-00025A Revision №: Version №:
Document Published Date: 06/07/2022 Last Review Date: 05/07/2022 Next Review Date: 05/07/2025 Doc Validity: 3 years