FORM CODE NO.

ASEPHIL MANUFACTURING CORPORATION AMC-HS-F01

TARLAC PLANT REPORT NO.: (YY-MM-00XN-CCC)

SUPERVISOR'S INCIDENT / ACCIDENT REPORT FORM

HOURS / DAYS LOST DATE & TIME OF OCCURRENCE DATE REPORTED STATION

1 PPE INVOLVED :
2 DESIGNATION :
3 LOCATION OF INCIDENT :
4 INCIDENT CATEGORY : (please check appropriate box)

F Personal Fire Vehicular

A Electrocution Others : Pls. specify :

C 5 SEVERITY OF INJURY : (please check appropriate box)

First Aid Non-Disabling Disabling Fatal

T 6 DESCRIPTION OF INJURY :

S
7 DESCRIPTION OF DAMAGE :

8 ESTIMATED COST : Direct Cost Indirect Cost

C a) Personal Injury ₱ ₱
O b) Property Damage ₱ ₱
S c) Others ( specify) ₱ ₱
T d) Total Estimated Cost ₱

9 CAUSE OF ACCIDENT :

Unsafe Act Unsafe Condition

10 DESCRIPTION OF ACCIDENT :

11 WITNESSES :
12 RECOMMENDATIONS TO PREVENT RECURRENCE :

(Supervisor's Name & Signature) (Safety Officer)

 FORM CODE NO.:

AMC-HS-F01
REPORT NO.: (YY-MM-00XN-CCC)

T / ACCIDENT REPORT FORM

STATION