HSE Incident Notification report

Incident details
Incident date / /2018 Incident time Date / time reported / /2018

Musanada PM Isameidin hassan Contractor Al Eslah Gen Cont Est Consultant Al Suweidi Engineering
ADFSP Phase 8
Project Name
Package 1

Incident Severity*
Serious (Injury / Illness / Dangerous Occurrence) Non-Serious (Injury / Illness / Dangerous Occurrence)
* Classification of this section shall be in reference to Occupational Safety & Health System Framework – Mechanism 11.0 – V3.0 – July 2016 (Schedules A, B & C)

Incident type
Fatality Property Damage Harm to animal
Occupational Injury Unsafe act Spill/Release/Discharge to Air
Occupational Illness Unsafe condition Spill/Release/Discharge to Land
Dangerous Occurrence Harm to Vegetation Spill/Release/Discharge to Water

Details of Injured Person(s)( if Applicable)

name age /sex
position nationality
date of hire/ ID contact details

name age /sex

position nationality
date of hire/ ID contact details

Witness Details
name department
contact details manager
name department
contact details manager

Injury
Please indicate body part injured on chart below
Strain / sprain Cut /laceration
scratch bruising
fracture dislocation
burn foreign body
Sting / bite
other

Treatment Given

hospital (admitted) doctor

first aid not required

Consequences of Incident

Lost time injury (days)

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Restricted work case (days)

Incident details
Describe in detail what happened – what, where, who and how. Include diagrams images and use additional pages if required

Analysis – mark ‘X’ against the factors which are thought to have contributed to the cause of the incident

task environment organizational human factors equipment

Lifting Housekeeping Poor communication Lack of experience Faulty equipment

Carrying Slippery conditions No policy/ procedures Lack of competence Lack of equipment
Repetitive movement Excessive noise Poor job design Stress / fatigue Poorly maintained
Twisting Weather conditions Hazards not identified Procedures not followed Wrong for task
Driving Heat / cold Lack of staff / budget Improper technique Lack of signage
Lighting /visibility Lack of training Physical limitations
Surface conditions Lack of supervision Skylarking / horseplay
Pressure to complete task

other

Corrective Action – what action is required to prevent the incident from happening again?
By who? By when?

Outcome of review of Risk Assessment

Report Preparation Review and Approval

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 name signature designation date
Prepared by Hashmi Safety officer
Reviewed by Zafeer Arif OSH Engineer
Approved by Ayham sabouni Project Manager

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