Zintex Telicommunications Accident Incident Report Doc-xxxxxxx

Section-1
Location Of Accident/Incident
Time Date Of Accident Incident

Name of Supervisor/Safety Officer Contact No

If this is an accident that required any form of medical treatment, go to 1: If this accident is just minor property damage with no person injured,
go straight to Box 2:

1 - Details of injured person 2 - Minor Property Damage only

Damage caused by:

Name
Age Date of Birth Buried Services strike
Employer: RTA
Injury sustaine Environmental
(and mark on diagram below) Theft
Others : Specify

3 -Equipment Involved
Vehicle Registration #
Plant Serial No

Material Description

Treated in Site First Aid or sent to Hospital: 4 - Other Companies involved

First Aid Hospital Company
hospital send
To Contact No
5 - Accident / Incident Description
Zintex Telicommunications Accident Incident Report Doc-xxxxxxx

SECTION B
6 - Immediate Causal Factor 7 - Contributory Causal Factor
A. Not following Procedures A. Physical capability / condition of person
B. Using incorrect or damaged tools / equipment
C. Safety Devices / guards not secure or emoved, or B. Hazards not identified on risk assessment / method statement
PPE not used
D. Inattention, lack of awareness or poor decision C. Lack of knowledge / training
judgement
E. Horseplay / Violence D. Conflicting instructions
F. Guards or PPE did not work correctly
G.Defective tools or equipment E. Poor supervision / leadership
H.Environmental (fire, noise, temperature, F. Poor planning / method statement
chemicals, act of nature)
I. Workplace environment (electrics, lighting, G. Poor storage of materials / equipment
ventilation, restricted space, housekeeping)
H. Poor tools / equipment used

I. No maintenance / servicing conducted on equipment

J. Policies & Procedures not enforced

8 - Photographs

09-Other documentation attached to this report:

Witness Statements Equipment Inspection records Operator Licences Risk Assessments Method Statement Pre-Task Briefing (TBT)
Other Training Records
10 Actions Taken
Initial (at time of accident):

Remedial (to prevent accident / incident occurring again):

Zintex Telicommunications Accident Incident Report Doc-xxxxxxx

SECTION C CLOSURE
11. Details of person filling out this report
Name Designation

Dept Date Of Submission

Closure Verification
Zintex have taken the necessary steps to ensure that similar incidents do not happen again in the future.We have informed all parties
involved of the results of our investigation and the measures taken to prevent future accidents. This closure verification confirms that
the accident has been properly investigated and all necessary steps have been taken to ensure the safety of all involved.

Name Designation
Dept Date Signature
Zintex Telicommunications Accident Incident Report Doc-xxxxxxx
Zintex Telicommunications Accident Incident Report Doc-xxxxxxx
 Doc-xxxxx-xxxx-xxxx
Zintex Telicommunications LIFE SAVING PRINCIPLES

Name of the Observer

Location Time