Doc.

code FM-HSE-014

Rev. 0
INCIDENT REPORT FORM
. Effectivity January 4, 2023

Account Name: Asian Development Bank Control No. AGS-IR-2024-006

Account Location: ADB Avenue, Ortigas Center, Mandaluyong Date: April 11, 2024

INCIDENT/ ACCIDENT CLASSIFICATION:

( ) Fatality ( ) Medical Treatment ( √ ) First Aid Treatment ( ) Near Miss ( ) Fire
( ) Property damage ( ) Property Loss ( )Pilferage ( ) Others: _________________

Incident:
An ADB international staff slipped in Level Ground B hallway area due to spilled chemical on the floor.

Brief description of Incident:

In the afternoon of April 11, 2024, around 4:25 PM, three (3) housekeeping personnel along with their shift
supervisor namely Angelo Vergara, Rochelle Faner, Sonia Chavez, and Frelan Ampuan respectively, were
passing through Ground B area near ADB Employees' Multi-Purpose Cooperative. They were scheduled to
clean the substations in basement 2. While passing by the area, the container of Taski Showplace (vinyl floor
wax) fell from the trolley and some spilled on the floor. As they are trying to mop the spilled chemical and
securing the area, an international staff passed by, not noticing the spilled chemical, slipped in the area and
accidentally bumped his head on the floor.

Immediate action taken:

An IRT personnel attended the staff that slipped in the area and brought him immediately in the medical
clinic for first aid treatment application. The area was secured and finished the removal of the spilled
chemical to avoid further incidents to happen.

Reported by: Noted by:

Frelan Ampuan