Incident report Date/time of event

Company North Department Site name

Type of event Injury Ill health Near miss

Harm (or potential for harm) Fatal or major Serious Minor Damage to property only
Employee involved in the event Name Carlo Palagud Address
Position Factory Worker Building 25, street 913, Zone 25, Al Mansourah
Doha, Qatar
Contact number 55654791
Brief description of event
(Details of what happened, when, where, and
emergency action taken)

Details of witness(es), if any

(Name, position, contact number, etc.)

Investigation required Yes Reportable Yes

Date/time reported
Investigation level High Medium Low Minimal
Priority Entry in accident book Yes
Leader of investigation Date/time entered

Reported by Position Date Signature

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Company Department Site name

Event details Employee(s) involved Location

Date
Time

Injuries or ill health effects, if any

Investigation details
Include details such as
- overview of the event
- activities being performed
- equipment used
- working conditions
- safety of working procedures
- maintenance
- competence of people involved
- workplace layout
- safety equipment used
- any other conditions which may have influenced the
event
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Causes of the event

Immediate causes Underlying causes Root causes

Which risk control measures should be implemented to prevent recurrence?

Risk control Planned completion date Actual completion date Manager responsible

Which risk assessments and safe working procedures need to be reviewed and updated?
Risk control Planned completion date Actual completion date Manager responsible
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Are there any further details that

should be mentioned?

Members of the investigation team Name Position Name Position

Signed on behalf of the investigation team

Name Position Date Signature

Report accepted by
Name Position Date Signature

The findings of this investigation need to be communicated to the following people

Name Position Date Signature