Incident / Accident Report

Project Name and Number: INTERNATIONAL SCHOOL MANILA

Company Name : MC GEOMETRIC PROPORTIONS INC.
Date: Time:
Weather : Location:

Worker's Name:
What type of work was being performed? Describe the accident, identifying all contributing factors. Attach
photographs.

Area of Injury. Specify Left or Right, if appropriate.

Names, addresses and phone numbers of witness if any.
Types of Accident/Incident/illnesses ,others: PROPERTY DAMAGE (WALL GLASS PANEL BROKEN )

What acts or conditions led directly to the incident?

REPORT IMMEDIATELY TO ISM FACILITIES REGARDING THE BROKEN GLASS INCIDENT AND INFORM ALSO TO
MCGPI PROJECT ENGINEER, SITE ENGINEER AND PROJECT MANAGER

What steps have or will be taken to prevent any similar incident i.e. Corrective Measures?

Person responsible for follow-up : Date: Time:

Follow-up completed : Date: Time:
Risk Evaluation
Potential of Reoccurrence: ❑High ❑Medium ❑Low
Potential of Injury: ❑High ❑Medium ❑Low

Project/Construction Manager: ENGR. DAN DE VERA, ENGR NAZHER HADJIRUL

Safety Coordinator/Officer: REYNALDO E. RAMOS

Project/Site Engineer: ENGR. DEXTER GLACITA , ENGR ROMCEL DURANA