ASSA CONSTRUCTION

INCIDENT REPORT
Format No: EHS/ASSA/003
Contractor:
Date:

What happened?
One Carpenter name Mumtaj Khan got cut on left hand during working on wall paneling
What caused it to happen?

 Headless nail used for laminate pasting.

When did it happen? (date and time): Where did it happen?

05.05.2022 11 :30 AM Room No 2 in DB site.

What would stop it happening again?

 Before proceeding for next day work on same location, removal of nails used earlier should be
removed.
 Proper housekeeping should be done near workplace

Was Property damaged? YES/NO If yes, what? NO

Was the environmental damaged? YES/NO If yes, what? NO

Any witnesses?: NO/If yes, No Name :

Was anyone Injured (YES/NO) : YES
Name of Injured Person? : Mumtaj Khan Age : 29 Phone: N/A
Home Address: NA
Was the injured person:  ASSA Const. employee  contract employee  Sub contractor employee
 Member of the public  other. Clients Vendor

What was the injured person doing at the time of injury?

He was pasting laminate sheets on wall

What was the injury and to what body part? Cut scratch on left hand.

How was it treated on site? The IP was rushed to the site first aid center for treatment.

Who performed this? First Aider

Referral for Medical Advice: First-Aid room Own Doctor  Other? Nearby tie up hospital.

Date of Occurrence: 05.05.22 Time: 11:35 Hrs.

Location: TATA DB(Forest Park,BBSR)

Report Date: Reporter:

Action Taken by whom and when:
Name & Signature of Construction Manager as having received this report : N/A

FORM STATUS Copy to Sent Comment

Mandatory.  Reporter PM & SO Copy to ....... Y ........
Optional (but with fills in Reviews Construction ................
intent on Yes head
Yes
file) . . . Prepared by File . . . . . . . . . . . . . . . .

Reported by:-
Site In charge