INJURY REPORT

 On-Site Injury Off-Site Injury

Date: ______________________
Project Title: Contract / CRC No.:

Name of Supervisor / Foreman: Location of Accident:

Date of Accident: Time of Accident:

A.M. P.M.
Name of the Injured Employee: Employee No.:

Trade: Occupation / Action at the Time Accident:

Nature of Injury: Part of the Body:

Accident Sequence: (How Did the Accident Occur?)

Unsafe Act (What Did the Employee or Other Person Do to Cause the Accident?)

Unsafe Condition (What Was Wrong With Machinery, Tools, Equipment, Work Environment, Etc.?)

Personal Protective Equipment (Is Glasses, Shoes, Helmet, Respiratory Devices, Etc. Used As Per
Requirement?)

Recommendations (What Will You Do to Prevent Recurrence of this Type of Accident?)

Supervisor/Foreman Signature Project Manager/Supt./In-Charge

DISTRIBUTION: Project Manager HSE Manager Project HSE Staff Originator Sr. Male Nurse
NOTE: 1. Orally notify project HSE Staff and Head Office – Admin. immediately.
2. This form to be duly completed, signed and sent within 12 hrs. for on-site injury.
3. In the event of a false statement, the signatory will suffer penalties as imposed by the Saudi Arabian
Government.
4. GOSI form must be sent to the concerned Male Nurse and Project HSE Staff together with this report.
All accidents result from an unsafe act or unsafe condition or both. The check list as attachment
will help to identify the causes.

Revision No. Page No. 1 of 2 Doc. No.

Prepared by: Management Representative Issued Date:
Reviewed by: HSE Department Manager Approved by: General Manager
Injury Report Attachment
CHECKLIST FOR IDENTIFYING KEY FACTS

A. NATURE OF INJURY
Foreign body Cuts Amputation Dermatitis
Bruises/Contusions Sprain/Strain Abrasion Illness
Puncture Wound Burns Suffocation Ganglion
Fracture Poisoning Hernia Others
B. PART OF THE BODY
Head Upper Extremities Body/Torso Lower Extremities
Scalp, Skull, Forehead Shoulder Back Hip
Neck Arms, upper Chest Thigh, upper leg
Face Forearm, elbow Abdomen Knee, lower leg
Mouth, Lips, Teeth Wrist, hand, palm Groin Feet, ankle
Eyes, Nose, Ears Fingers Others Toes
C. ACCIDENT TYPE
Struck by (flying, moving, falling, sliding objects) Slip, trip and fall (same level)
Struck against (rough, sharp objects, etc.) Falls (on different levels)
Contact with hot surfaces, high temperature Poisoning (inhalation, adsorption, ingestion)
Caught in or between Burns (chemical contact, etc.)
Overexertion (result in strain, body pain, hernia, etc.) Others
D. AGENCY OF ACCIDENT
Machines and equipment, moving parts, shafts, Pressurized vessel, pipes, boilers, etc.
conveyors, cranes, hoists, etc.
Platforms, stairs, steps, ladders Materials (sheet, stock, scrap, etc.)
Chemicals Vehicles
Building (door, pillar, wall, window, etc.) Floors or level surfaces
Electrical Foreign body
Hand Tools Others
E. UNSAFE CONDITION
Improper or inadequate guards Unsafe design or construction
Unguarded Hazardous arrangement
Defective tools, equipment, substances Improper illumination
Improper ventilation Congested area
Poor housekeeping Others
F. UNSAFE PRACTICES
Operating without authority Making safety devices inoperative
Failure to warn or secure Using defective equipment, tools
Operating at unsafe speed Unsafe operation of equipment or vehicles
Failure to use PPE Unsafe loading, mixing
Unsafe lifting or carrying i.e. insecure grip No unsafe acts
Adjusting, cleaning, equipment in motion Others
Taking unsafe positions
G. CONTRIBUTING FACTOR
Disregard of instructions Non-compliance of job precautions
Bodily defects Act of other than injured
Failure to report to medical department Lack of knowledge or skill
Incomplete or insufficient instructions No contributing factors
Tools and PPE not provided Others

Note: Tick appropriate column or box.

Revision No. Page No. 2 of 2 Doc. No.

Prepared by: Management Representative Issued Date:
Reviewed by: HSE Department Manager Approved by: General Manager