S056b Property Damage Report (PD 00XX)

Contractor PSH-JV Project Name :Date

Sub Contractor PSH Metro Green Line :Time

:Reported by :Location Report No. PD 00XX

Name:
Email:
Phone: [Admin to fill]
Designation: ISMS #
INCIDENT DESCRIPTION

IMMEDIATE CORRECTIVE ACTION TAKEN

1.

2.

3.

RECOMMENDATION/S TO AVOID RECURRENCE

●

Safety Engineer: Approved by HSE Manager:

Name Name
Email Email
Phone Phone

Page 1 | 3
Section Health & Safety
Status Controlled
Reference S056b
Date January 31, 2014
 S056b Property Damage Report (PD 00XX)

WEATHER (describe)

EMERGENCY SERVICES CALLED? (if yes who, what, when?)

NON EMPLOYEE WORKERS INJURED?

- INJURED COUNT: XX
- MEDICAL TREAMENT RECEIVED?
- DID THE EMPLOYEE RETURN TO WORK?

MEMBERS OF THE PUBLIC WERE INJURED

- INJURED COUNT: XX
- DESCRIBE:

EQUIPMENT INVOLVED

- TYPE OF EQUIPMENT:

- REGISTRATION NO./LICENSE

PROPERTY DAMAGE

- DESCRIBE:

- QR ESTIMATE VALUE:

INCIDENT PROJECT DELAYS/IMPACT (ESTIMATE IF KNOWN)

- NO. OF PEOPLE: XX
- DAYS IMPACTED/DELAYED: XX

Page 2 | 3
Section Health & Safety
Status Controlled
Reference S056b
Date January 31, 2014
 S056b Property Damage Report (PD 00XX)

Page 3 | 3
Section Health & Safety
Status Controlled
Reference S056b
Date January 31, 2014