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EOHSMS-05-F01 Incident & Accident Investigation Report Form
EOHSMS-05-F01 Incident & Accident Investigation Report Form
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EOHSMS-05-F01_Rev0
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INCIDENT / ACCIDENT OCCURRENCE REPORT FORM / INVESTIGATION REPORT PART A (Type of Incident / Accident) Major Incident / Accident Minor Incident / Accident Staff Injury /Public Member Injury PART B (Details of Incident / Accident) Project : Place of accident : Occurrence date & time: First reported date & time: Reported by: PART C (Details of Injured / victim) Name : Employed by : Direct Employer : Employed by : Date of Birth : Gender : Race : Date Joined Service :
EMPLOYEE SENT TO: First Aid Private Doctor Hospital Polyclinic Name of clinic / Hospital: PART D (Lost Time) Estimated (if actual mandays lost is not available) 3 days or lesser More than 3 consecutive days Hospitalized more than 24 hour Immediate return to work First aid given only Hospital referral State actual of man-days lost:
AMP : Amputation BCC : Bruises/Crushing/Contusions BN(H) : Heat Burns CCS : Concussion/Internal Injury DIS : Dislocation EYE : Eye Injury FT : Fracture HEAT : Heat Stress and strain NID : Noise Induced Deafness PERM : Permanent Disability PSN : Poisoning RDT : Effects of Radiation SS : Sprain/Strain OTHER : Other Injury
HAND LOWER NA
Nature of Injury
ii ) Unsafe Practice Careless/ reckless Disregard instructions Driving error Failure to secure / warn Horseplay Under influence of alcohol/drugs Improper/wrong use of body part Improper/unsafe lifting/carrying Improper working methods & sequence Unsafe loading/mixing/placing Intentional motive Remarks:
Taking improper/unsafe position or posture Making safety devices not in operative mode Not attentive while during working Operating/working at unsafe speed Operating/working without authority Tampering with equipment in motion Using improper/unsafe equipment Using proper equipment unsafely Fail to use proper tools/ equipment Others (key details into Remarks)
Inadequate/lack of work procedures Pressure from external influence Poor selection/placement Wear and tear Others
PART I (Recommendation)
PART J (Details of Investigation recorded by) Investigated by : Name: Designation: Company: Date: Reviewed by : Name: Designation: Company: Date:
EOHSMS-05-F01_Rev0 Page 4 of 4
Signature:
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Signature: _________________
Issued on 15 Sept 2010