DEMOLITION AND CLEAN UP WORKS FOR NEOM

HSE-F-NEOM-007

Contract Number: 100187

REV:00

PRELIMINARY ACCIDENT REPORT ISSUE DATE: 14-April-2019

DETAILED REPORT TO BE SUBMITTED WITHIN 3 DAYS

INCIDENT/ACCIDENT- PERSON, MOTOR VEHICLE, EQUIPMENT OR PROPERTY
 Motor Vehicle Accidents  Personal Injury  Environment  Near Miss
Date: Time: Location:
Describe Incident/Accident:

Immediate Corrective Action (s):

Company (if Subcontractor): Injured Person Name: ID #:

Injury or Illness: (Attach First Aid/Medical Witness Statement: (Attach full statement to this report)
Report)

MOTOR VEHICLE (ADDITIONAL INFORMATION)

Driver Name: ID #: Vehicle Plate #:

Accident Involved the following Private Vehicle: Subcontractor Vehicle Fixed Object

Others:
No. of People in How Many Injured?
Vehicle 1
No. of People in How Many Injured?
Vehicle 2
Who reported to the accident scene?
Safety Officer Police Others:
(If yes, attach the report)
Prepared By: Approved By:
Position: Position:
Signature: Signature:
Date: Date: