Title: EHS Accident/Injury Report Form Page 1 of 2

Doc Code: Rev. No. 0

EHS ACCIDENT/INJURY REPORT FORM

PART A INJURY / ILLNESS

Name of victim Affected Area  Business Unit: ____________

 Contractor: _______________
Job Title Department
Gender Age
Date Date Location of
Time of Incident Time Reported Incident
Type of Incident  Near Miss  Accident  Property Damage
 People  Injury  Fire / Explosion  Chemical spill or leak
 Property  Illness  Vehicular accident  Others: ____________
 Animal bite
Injury Illnesses Parts of body affected:
 Wounds, Cuts &  Skin irritation  Head
Laceration  Eye irritation  Eyes
 Bruises, Contusion  Respiratory disorder  Nose
 Hematoma  Poisoning (Chemicals,Other Metals, Food)  Ears
 Puncture  Disorder due to repeated trauma (Noise induced hearing  Mouth
 Crushing loss, Carpal tunnel syndrome)  Shoulder
 Fracture  Heat stroke  Chest
 Burn (Chemical or  Heat Exhaustion  Abdomen
Electrical)  Stress  Hip
 Electric shock  Emotional trauma  Arm
 Strain, Sprain,Tear  Nervous shock  Hand
 Amputation  Sikness / Flu  Fingers
 Multiple Physical  Infection  Fingers
Injuries  Inflamation  Knee
 Fatality  Suffocation  Ankle
 Others : __________  Dermatitis  Feet
 Fracture / Dislocation  Toes
 Contagious disease  Whole body
 All other occupational diseases  Others: ____________
 Others: _______________________________________
1st Occurrence Recurrence: _____________ Emergency response action needed?
___________________________________________
SUMMARY OF THE INCIDENT
(NOTE: Be as detailed as possible. Attach additional sheets where necessary. Include pictures, sketches and lay-outs, where possible.)

A. PROBLEM DESCRIPTION: (use separate sheet if necessary)

What: When: Where: Who:
_________________________________________ ______________ _____________ _______________
How: (Attached pictures when necessary)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
 Title: EHS Accident/Injury Report Form Page 2 of 2
Doc Code: Rev. No. 0

B. ROOT CAUSE (Why)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
C. LESSON LEARNED
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PART B PROPERTY DAMAGE
EXTENT OF DAMAGE
 Property No of Equipment:  Area Covered Approx. area:
 Injuries No of Person/s:  Equipment damage:
 Death No of Person/s:  Estimated replace/repair cost:
PART C REPORTING REQUIREMENT
CORRECTIVE & PREVENTIVE ACTIONS (Use separate sheet if necessary)
Action plan Responsible person Department Completion date

REPORTED BY: INVESTIGATED BY: WITNESSED BY:

_________________________ ___________________________ _________________________
PRINTED NAME & SIGNATURE PRINTED NAME & SIGNATURE PRINTED NAME & SIGNATURE

___________ __________ __________ __________ ___________ ________

DESIGNATION DATE DESIGNATION DATE DESIGNATION DATE

REVIEWED BY: NOTED BY:

___________________________ ___________________________
PRINTED NAME & SIGNATURE PRINTED NAME & SIGNATURE

____________ __________ ____________ __________

DESIGNATION DATE DESIGNATION DATE
Post meeting required?  No  Yes (Attach Minutes of post meeting or equivalent record for filing)