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Incident Report
Complete

Score 100% Flagged items 0 Actions 0

Audit Title  

Document No. 000001

Client / Site  

Conducted on 04.03.2023

Prepared by Arif khan

Location

Personnel  

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1.Audit-100%
Audit 100%  
1.1.SECTIONI-100%
 
SECTION I 100%

Date and time of incident

Date and time incident was reported.

To whom was the incident reported?  

incident was firstly reported to the site supervisor which was pm by position

Location of incident. (Specify site location)  

Project site

Supervisor's Name  

Supervisor's Phone Number  

0000000000

Was there any witness(es)? If yes, provide name(s). Yes

1.2.PERSON(S)INVOLOVED-100%
 
PERSON(S) INVOLOVED 100%

Name (Person 1):  

tipu was involved in the incident as he pulled the ladder while he was walking down the side of
ladder unintentionally and resulted in skidding of the ladder

Phone:  

000000000

Sex: Male

Age;  

29

Job Title:  

labor

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Time on job: (Yrs & Mos)  

Job Status:  

Classification: Medical

Employee Disposition Status:  

Medication prescribed? If yes list medications. Yes

1.3.NATUREOFINJURY
 
NATURE OF INJURY  

Describe injury.  

breaking of the ankle due to sudden impact as landed abruptly on ground ,resulting in twisting of
the ankle ,now needs time to recover that with plastic bandage

Detail any first-aid or medical treatment administered.

 
(Provide names)

yes first aid treatment was given on site

Property Damage: None

Photo of damage.  

Property Damage: Equipment

Photo of damage.  

Estimated cost of damage:  

Vehicle ID:  

Make/Model:  

Age:  

Equipment ID:  

Model:  

Age:  

Detailed description of incident. (Include environmental

 
conditions at time of incident)

Tipu was carrying the tools in his hands as he passes by the ladder he makes contact with the
ladder on which already one worker was standing so the balance of ladder was disturbed resulting
in an incident of worker falling on the ground with sudden impact ,weather was clear and no root
cause of the accident is linked to the environment.We assume it involves the lack of concentration

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and which resulted in this scenario

Environmental photo:  

Environmental photo:  

Immediate (Direct Causes):  

Direct cause photo:  

Direct cause photo:  

Contributing (underlying) Factors:  

Contributing factors photo:  

Corrective Action (Include detail description of action and

 
person(s) responsible for actions)

What was the potential for severity? Serious

What could have potentially happened?  

it could have potentially lead to the death of the worker if he could have fallen on the concrete
blocks nearer to the ladder but fortunately it did'nt happened

What is the probability of reoccurrance? Remote

Signature  

04.03.2023 15:54 +03

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