DETAILED INCIDENT / ACCIDENT INVESTIGATION REPORT

General Report Details

Report No: Project: Contract No:

Accident Location: Date:
Time:
Full Description of Event (add pages, notes, photographs, sketches, statements, and any other documents attached as necessary) :

Injury Classification: Fatality Serious Moderate Minor Tick box(es)

Other Classifications: Dan/Occ. RTA Fire Near-miss Enviro.

Environmental Damage: Yes No Attach any Police, DM, local authority, or other reports.

Description:

Initial Notification Report Number: Attach copy of initial notification for reference

Police or Local Authority Report Attached Yes / No Attached photos / sketches / diagrams Yes / No

Injured Person’s and Injury Full Details

Full Name (as in Passport) Job Title / Designation
Employee ID Number Date of Joining
DOB: Age: Gender M/F Experience years
Attached pay or other personal details Yes / No Attached hospital, nurse, or first aid report Yes / No
Immediate Supervisor’s
Phone Number
Name

Parts of the Body Affected by the Injury

Head Body Arm Leg Face Multiple
Neck Back Hand Foot Eye General (not specified)

Other:

Nature of the Injury

Abrasion Burn Scald/Chem. Dislocation Poisoning Unconscious
Amputation Bruise / Contusion Electric Shock Puncture Other:

Asphyxiation Laceration / Cut Fracture / Crush Sprain / Strain

Description:

Medical attention received

Casualty
First Aid Co. Doctor/ Nurse Referred to: Hospital
Received:
Transferred to home (accomm.) Return to work Moved to perform another task

Document No AFC-HSE-F04 Rev 00

Revision Date 01-06-2017
Status of the Injured Person at the time of the accident. Yes No N/A
Did the accident occur during official working hours?
Was the injured person authorised to carry out this task?
Was the injured person trained to do this task?
Was the injured person being supervised at the time of the accident?
Was the correct equipment, tool(s) or materials used?
Was the injured person using the proper PPE?
Was the machine guarded?
Was the guard in use at the time of the accident?
Was the energy source (electricity, compressed air, etc.), on machinery the employee
was servicing, isolated at the time of the accident?
Was the injured person working on a scaffold, platform, stairs, or roof?
Was the height of the platform, stairs, or roof more than 2m (6 feet)?
Was first aid available at the location?
What procedures (immediate actions) were taken at the time the accident occurred?

Other People Involved

Names of People Involved ID No. Designation Reason For Involvement
1
2
3
4
Witness Statements Attached? Yes / No Translations of any documents attached? Yes / No

Conditions of Working Environment and Atmosphere

Wet Dry Hot Cold Storm(sand) Storm (Rain) Mist
Lighting arrangements Ground (Surface) Condition
Good Weak Natural Artificial Level Un-level
Housekeeping and surface area (what was present that should not be there?)
Water Oil Dye Const. Debris Tools Eqpt. Others

Accident Causation
What caused the Accident: Immediate Causes: (state whether Unsafe acts (by a person) or Unsafe conditions (surrounding environment)

Basic Causes:

Document No AFC-HSE-F04 Rev 00

Revision Date 01-06-2017
Root Causes:

Estimated Cost (all amounts in AED)

Medical Salary / Wages Damages Repairs Other
Nurse Injured Party Equipment Labour Hired Vehicles

Product
Doctor Witnesses Property Supervision
Replaced

Ambulance Replacement Materials Material

Hospital Investigator Product Machinery

Medication

Sub-Total

Grand Total

Corrective/Preventative Action to Be Taken Please sign below to acknowledge the action is to be carried out or to confirm that it has been completed.
Item
Corrective/Preventative Action Action party Target Date Signed Off
No.

Lessons Learnt:

Accident Close Out: This report has been reviewed and in the opinion of the management (signed below) sufficient action has been taken to ensure, as far as reasonably
practicable, the risk is reduced to acceptable levels.

Job Title Name Signature Date

Project Controller

Project Manager

HSE Manager

Site HSE Representative

Distribution:
Project Project Construction
HSE Manager CPE Manager
Controller Manager Manager
Contracts Client / Project HSE
Admin Manager Others
Department. Consultant File

Document No AFC-HSE-F04 Rev 00

Revision Date 01-06-2017