PRECA SOLUTIONS INDIA PVT LTD

ACCIDENT / INCIDENT INVESTIGATION REPORT

Department: Location :
Date & Time of Incident :
Brief of Incident :

Name Of Injured Person Designation Age:

1
2
3
Body Part Injured:

Type Of Incident :
Lost Time Injury

Occupational Illness Dangerous Occurrence /Near Miss

Classification Of Incident :
Unsafe Act

Cause Of Incident Or Condition

Lack Of Attention Poor Documentation

Failure to follow proper procedure Improperly Prepared Procedure

Lack Of Communication Congested Area

Unfamiliar With The Equipment See below Poor Design

Unfamiliar With Operating Procedure Improper Equipment

Carelessness Improper Installation

Any Other ( Pls. Specify)

 Description Of Incident:

Initial Response & Reporting

Prepared by Safety Officer / Site Incharge

Name
Signature
 ACCIDENT / INCIDENT INVESTIGATION REPORT

Facts Gathering

Key Witnesses Interviewed People):

Name : Details of Input
1
2
3
4
5

Observations / Findings at Site & Records:

1

2
3

Contributing Causes
Physical Causes:

People Causes:

System Causes:

Corrective & Preventive Actions Taken

Elimination:

Administrative Controls:

Recommendations
Sr.No. Recommendation

2
 3
Is Root Cause Analysis done:

Investigation Team Members

Name Signature

Communication done to All users, Inter location : Yes / No

Receipt of CAPA & Closure : Yes / No

Verification of Closure by EHS-Incharge Approved by

Name Name
Signature Signature
Date Date
 Doc No :SF- 11 A
VT LTD
N REPORT

Job Code
Incident No:

Type Of Injury

Rest Recommended:

First Aid Case (FAC)

gerous Occurrence /Near Miss

nt :
Unsafe Condition

dition

ared Procedure
nt:

rting
PORT page no:2

ons Taken

Target Closing
Action by Closed by
Date Date
 Cost of Accident:

Date

Approved by Project Incharge

me
nature
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