FIRST INCIDENT REPORT Report No: BI/ 01/ 2024

Type of Incident 1st Aid/ Minor Injury Medical Injury Fire / Property Damage

Lost Time Injury Others Near Miss

DATE : Time Location: Project No.

Name of the Person Designation : ID No / Age:

Experience in Industry Experience in UAE: Qualified for the task: Yes No

Type of activity was carried out :

EQUIPMENTS INVOLVED

Description of incident:

ACTION TAKEN:

Incident Analysis by HSE:-

Severity Probability Risk Significance

Minor Major Continuous Frequent Unlikely Low High

Moderate severe Occasional Remote Medium

RECOMMENDATION BY HSE :-

FURTHER INVESTIGATION REQUIRED: YES NO

INSURANCE CLAIM: YES NO

FOR PROPERTY DAMAGE VEHICLE PERSONNEL

DESIGNATION NAME SIGNATURE

Production / Site Engineer

HSE Engineer

Production / Operation Manager

BERG/FO/HSE-01, Rev 00