Investigating, Reporting, Records

Accident
Reporting,
Investigating
and Records
Safety Module: Accidents, Rev 0.0, Mar 2007

Reporting of Accident

Reporting Of Accidents
Whether accidents in factories are to be

reported?
• Accident means an event leading to damage to man, machine,
material, time or environment.
• Every accident wherein, as a result of injury, a worker is likely
to absent himself from work for more than 48 hours, shall be
reported within 24 hours to the Inspectorate;
• Any of the specified dangerous occurrences shall be reported
within four hours, in the prescribed form.
• Fatal accidents have to be reported within four hours either by
telephone, special messenger or telegram.

Safety
Committee

Safety Committee
Is it necessary to have a safety committee?

• As per rule 41G (1) The occupier should set up
a safety committee consisting of equal no. of
representatives of workers and management to
promote cooperation and maintain safety and
health at work place & review periodically the
measures taken in that behalf provided it is not
exempted by state Govt. in writing.

Medical Examination Of Workers
Section 41C
• Is it compulsory that all workers in a factory are to

be medically examined?
• The Factories Act prescribes for pre-employment and
periodical medical examinations of workers employed in
certain hazardous processes. The periodicity and the
nature of medical examinations vary according to the
nature of process to which an individual worker is
exposed to.
• All the workers are subjected to pre-employment and
periodical medical examinations.
• Tests w.r.t.schedule-1 industries
• Diseases as per schedule-3

Accident reporting
Why Accidents are to be Reported ?
• Minor injuries occur in more numbers than serious injuries and

record of these are helpful in attending the problem.
• This attention prevents the serious injury to take place.
• For effective, accident preventive measures identification.

Why reporting Accidents
Objectives:
• Prompt report of accidents & dangerous occurrences

• To comply the requirements / obligations under
different statutes
• To inform the concerned authorities with in the
organisations
• To keep complete information of accidents for record
and analysis, which help in taking preventive
measures
• To obtain information on injuries

Reporting Procedure of Accidents
Section in-charge
1. Refer the injured person to dispensary / first aid

centre with a preliminary report on Form –I;
2. Inform to HoD, Head of HR, Head of safety over
telephone with full description of accident
3. In case of injury to contractor’s employee, the
contractor will immediately inform to NTPC officer

FORM-I
To
Chief Medical Officer,
Sub:- Accident to Shri/Smt XXXXXX
Shri/Smt XXXXX is referred to hospital for treatment.
The details of the injured and incident are as below:
1. Designation of injured:
2. Employee No:
3. Department:
4. Date & time of accident:
5. Details of accident:
6. Cause of the accident:
Date: Signature
Name :
Designation:
Safety Module: Accidents, Rev 0.0, Mar 2007 Department:
• In case the injured person is taken directly

hospital, the in-charge of hospital will inform about
the injury to HoD in Form-II with a copy to Head of
HR, head of safety or inform over phone in case of
serious injury
• The HoD will prepare a detailed report of accident

with 4 hours of the accident in Form-III with a
copy to GM (Station) and Head of HR, third &
fourth copies to Head of Safety and fifth copy will
be retained by the HoD.

FORM-II
Date:
To
HOD
Shri XXXX Employee No. YYYY Designation ZZZ of your dept/

Section has reported to First Aid Post/Hospital for treatment of
work injury without Form-I. He has been made fit / unfit to work
for less than/more than 48 hours.
Please expedite Form-I, if it is a work accident.
Medical Officer/Dispensary Incharge

Incharge/First Aid Post
Copy to:
Personnel Head
Safety Dept.
FORM-III
1. Injured Person’s full name and address :
2. Employed by:
3. a) Sex:
b) Age on last birth day :
c) Designation of injured person:
4. Date and hour of accident:
5. Full address of the place, where accident happened.
6. Branch or Dept., and exact place where accident happened:
7. Hour at which he started work on the day of occurrence:
8. a) Cause or nature of accident:
b) Is it caused by machinery if yes,:
i) Give name of the machine and part causing the accident.
ii) State whether it was moved by mechanical power at that time.
c) State exactly what injured person was doing at the time.

FORM-III
9. Nature and extent of injuries (e.g. fatal, loss of finger, fracture of
leg, scaled scratch followed by sepsis).
a) Location of injury (right leg, left hand or left eye etc).
10. Number of days for which the injured person is likely to be off
the work.
a) i) If the accident is not fatal, state whether the injured
has returned to work.
ii) If so, date & hour of return to work
b) i) Has the injured person died:
ii) If so, date & time of death:
11. Was the injured person wearing proper personal protective
equipment.
a) Safety belt :Yes / No
b) Safety helmet :Yes / No
c) Safety shoe :Yes / No
d) Safety goggles :Yes / No
e) Hand gloves :Yes / No
f) Any other personal protective equipment provided by
Management (specify) :

FORM-III
12. Whether any safety guard/system is by passed:

13. Name of Doctor/hospital from where the injured person
received or is receiving treatment. :
14. Name of person, who saw the accident and can give important
evidence.
15. In your opinion was the accident directly attributable to
i) the injured person having been at that time under the
influence of drink or drug.
OR
ii) the willful disobedience of the injured person to an order
expressly given to a rule expressly framed for the purpose of
securing the safety of employee.
OR
iii) the willful removal or disregard by the injured person of any
safety guard or other devices which he knows to have been
provided for the purpose of securing employee’s safety

FORM-III
16. Describe briefly how accident occurred:
Date:
Section Incharge :
Time: Name :
Designation :
Distribution:
1st Copy of GM thro’ HOD.
2nd & 3rd Copies to Safety Dept.
4th Copy to Personal Head.
5th Copy for office record.
– In case the injured person is disabled for 48 hrs

or more from the time of the accident, the
concerned HoD will fill up Form-18 and will
submit to Head of Safety after obtaining
signature of the manager of factory for onward
submission to Statutory authorities.
– Head of Safety will send the Form-18 to

statutory authorities with in 72 hours from the
time of accident

Notice of Accident or Dangerous Occurrences
Resulting in Death or Bodily Injury
Form 18 (Delhi factories rules)/ Form 22 (MP factories rules)
1.Name of the Occupier (or Factory)

2.Address of works
3.Nature of Industry
4.Branch or Department and exact place where the accident or
dangerous occurrence happened
5.Injured person’s name and address
6.a. Sex………….
b. Age………….
c. Occupation of Injured persons………
7. Date and hours of accident or dangerous occurrence
8.Hour at which he started work on day of accident

9.a. Causes or nature of accident or dangerous occurrence

b. If caused by machinery
(i) Give name of the machine and parts causing the accident or
dangerous occurrence and
(ii) State whether it was moved by mechanical power at the time.
c. State exactly what injured person was doing at the time.
10.Nature or extent of injuries (e.g. Fatal loss of fingers,

fracture of leg, scald, scratch followed by sepsis)
11.If accident or dangerous occurrence is not Fatal state
whether injured person who disabled for 48 hours or more.
12.Name of Medical Officer in attendance on injured person.

• I certify to the best of my knowledge and belief the above

particulars are correct in every respect.
• Signature of Occupier or Manager

• Date of dispatch of report
• District…………….
• Date of receipt…………….

• Number of Accidents or Dangerous Occurrences…………………
• Industry No…………
• Causation No…………….
• Sex (Man)
(Woman)
(Boy)
(Girl)
• Other Particulars e.g. (fatal)

(leg injury)
(arm injury)
(etc.)
• Date of investigation……………..
• Result of Investigation……………
• In case of fatal accident, information of the accident will be

immediately intimated to corporate centre and statutory
authorities by quickest mode of communication
• Form-18 is to be submitted to statutory authorities
immediately.
• In case of dangerous occurrence, section in-charge will
inform to Head of Safety, Head of HR, Head of Department in
Form-VII with in 4 hours
• Head of Safety will intimate such dangerous occurrences to
statutory authorities in Form -18a

FORM-18
(Prescribed under Rule 96 and under regulation 68 of
Employees State Insurance Act 1948)
NOTICE OF ACCIDENT OR DANGEROUS OCCURRENCE
RESULTING IN DEATH OR BODILY INJURY
1. Name of occupier (Factory/Employer) :
Employee’s State Insurance Employee’s : N.A

Code No.
2. Address of works/premises where accident or dangerous occurrence took place
3. Nature of Industry :
4. Branch or Department and exact place where the accident or dangerous
occurrence took place.
5. Employees State Insurance number : N.A
(if covered)
6. Name and address of the injured person :
7. (a) Sex :
(b) Age (last birth day) :
(c) Occupation of the injured person :
(d) Monthly wages of the person injured :

FORM-18
8. Local Employees State Insurance office : N.A.
to which the injured person is attached.
9. Date, shift and hour of accident or dangerous occurrence
10. (a) Hour at which the injured person started work on the day of accident or
dangerous occurrence.
(b) Whether wages in full or part are payable to him for the day of the accident
or dangerous occurrence.
11. Cause or nature of accident or dangerous occurrence.
( a) If cause is by machinery
(i) give name of the machine and the part which involved in the accident or
dangerous occurrence. :
(ii) State whether it was moved by Mechanical power at that time.
(b) State exactly what the injured person was doing at that time.

FORM-18
(c) In your opinion, was the injured person at that time of accident or dangerous
occurrence
(i) Acting in contravention of provision of any law applicable to him, or
(ii) Acting in contravention of any orders given by or on behalf of his employer, or
(iii) Acting without instructions from his employer:
(d) In case reply to ©, (i), (ii) or (iii) is in the affirmative, state whether the act was
done for the purpose of and in connection with the employee trade or business.
12. In case the accident or dangerous occurrence happened while traveling in the
employer’s transport, state whether
(i) the injured person was traveling as a passenger to or from his place of
work.
(ii) the injured person was traveling with the express or implied permission
of his employer.
(iii) the transport is being operated by or on behalf of the employer or some
other person by whom it is provided in pursuance or arrangements made with
the employer, and
(iv) the vehicle being/not being operated in the ordinary course of public transport
service.

FORM-18
13. In case the accident or dangerous occurrence happened while meeting an
emergency state.
(i) It’s nature :
(ii) Whether the injured person at the time of accident or dangerous occurrence
was employed for the purpose of his employer’s trade or business in or about the
premises at which the accident or dangerous occurrence took place.
14. Describe briefly how the accident or dangerous occurrence occurred.
15. Name and address of witnesses : 1.
2.
16.a) Nature and extent of injury (e.g., fatal, loss of of fingers, fracture of leg, scald or
scratch and followed by sepsis)
b) Location of injury is (right leg, left hand or left eye etc.)
17. a) If the accident is not dangerous occurrence and is not fatal state whether the
injured person was disabled for more than 48 hrs.
b) date and hour of return of work :

FORM-18
18. a) Physician, dispensary or hospital, from whom or in which, the injured person received or is
receiving treatment.
b) Name of dispensary /panel doctor elected by the injured person.
19. i) Has the injured person died :

ii) If so, date of death :
I certify that to the best of my knowledge and belief the above particulars are correct in
every respect.
SIGNATURE
NAME AND DESIGNATION OF
OCCUPIER OR MANAGER/EMPLOYER
Date of dispatch of Report.
Employer’s address and
Code No.

FORM-18-A (Prescribed under Rule 96)
Notice of dangerous occurrence which does not result in
death or bodily injury
1. Name and address of the Factory :
2. Name of the Occupier :
3. Name of the Manager :
4. Nature of Industry : Power Generation
5. Branch or Department and exact place :
where the dangerous occurrence took place
6. Date and hour of occurrence :
7. Nature of Dangerous Occurrence :
(state exactly what happened)
I certify that, to the best of my knowledge and belief, the above particulars are correct
in every respect.
SIGNATURE OF THE OCCUPIER/ MANAGER
Date of dispatch of report:
NOTE: To be completed in legible handwriting or preferably typewriting .
_____________________________________________________________________
(This space is to be completed by the Inspector of Factories)
District:
D. No.
Causation No. Date of receipt:
Result of investigation Date of investigation:
Accident/dangerous Occurrence Reporting Procedure
Sl. Nature of injury Type of Due time Signatory

No form Distribution
.
1. For minor or major Form-I Immediate Any Executive Head of Department
Of the Head of Hospital,
Department Head of Safety
Head of Personnel
For minor or major (if Concerned Head of Dept
2. Form-I is not received Form-II Immediate Attending Head of Safety
by doctor) Doctor Head of personnel
3. For minor or major Form-III Within 4 Section In- General Manager
hours charge Head of Safety (2 copies)
Head of Personnel
4. Fatal Accident Form-18 Immediate Factory Mgr Head of Safety
ie. AGM(O&M) (3 copies)
5. Accident that disable the Form-18 Within 48 hrs
injured for attending from the time of Factory Manager Head of Safety
duties 48 hrs., or more. occurrence of i.e., AGM(O&M) (3 copies)
accident.
6. For dangerous Form- Within 12 Factory manager Head of Safety (4
occurrence 18A hours i.e., AGM(O&M) copies)
Note:- However, irrespective of the nature & severity of accident whether minor or major,
should be informed to Safety Dept., immediately on telephone .
Reporting of Accident
Sub Rule -2;

• Once the notice is received by the authority they
have to inquire into the occurrence with in one
month of the receipt of the notice.
Sub Rule -3;

• The state Government may make rules for
regulating the procedure for inquiries under this
section.

Notice for Certain Dangerous Occurrences
According to Section (88-A),of The Factories Act 1948;
The dangerous occurrence causing any bodily injury

or disability or not, the manager of the factory shall
send notice there of to appropriate authority in a
prescribed form.

Notice for Certain Diseases
According to Section (89) ,of The Factories Act 1948
Sub Rule (1) ;

• Where any worker in a factory contracts any disease
specified in the third Schedule the manager of the
factory shall send notice such authorities in a
prescribed form.

Sub Rule (2) ;

• If any medical practitioner confirms any disease
specified in the Third Schedule the medical
practitioner shall without delay send a report in
writing to the office of the Chief Inspector stating.
• The name and full postal address of the patient.
• The disease from which he believes the patient to
be suffering and
• The name and address of the factory in which the
patient is, or was last employed.

Sub Rule (3) ;

• If Chief Inspector is satisfied with the certificate of
a certifying surgeon that the person is suffering
from a disease specified in the Third Schedule he
shall pay to the medical practitioner such fee as
may be prescribed and the fee so paid shall be
recoverable as an arrear of land-revenue from the
occupier of the factory in which the person
contracted the disease.

Sub Rule (4) ;

• If any medical practitioner fails to comply with
the provisions of sub section he shall be
punishable with fine which may extend to one
thousand rupees.
Sub Rule (5) ;

• The Central Government may, by notification in
the Official Gazette, add to or alter the Third
Schedule and any such addition or alternation
shall have effect as if it had been made by this
Act.

Power to direct inquiry into cases of accident or disease
According to Section (90), of The Factories Act 1948;

Sub Rule (1) ;
• The State Government may appoint a competent person to inquire
into the causes of any accident or disease specified in the Third
Schedule.
Sub Rule (2);

• The person appointed to hold an inquiry under this section shall have
all the powers of a Civil Court under the Code of Civil Procedure,
1908 (5 of 1908) for the purpose of enforcing the attendance of
witness and compelling the production of documents and material
objects, and may also so far as may be necessary for the purpose of
the inquiry exercise the powers of an Inspector under this Act,
• and every person required by the person making the inquiry to
furnish and information shall be deemed to be legally bound so to do
within the meaning of section 176 of the Indian Penal Code (45 of
1860).

Power to direct inquiry into cases of accident or disease
Sub Rule (3);

• The person holding an inquiry under this section
shall make a report to the State Government stating
the causes of the accident, or occupational disease.
Sub Rule (4);
• The State Government may, if it thinks fit, cause to
be published any report make under this section or
any extracts there from.
Sub Rule (5);
• The State Government may make rules for
regulating the procedure at inquires under this
section.

Notification of accident and dangerous occurrences
According to Section (108), of The M.P. Factory Rules

1962;
Sub rules (1);
• When any accident which result in the death of any
person or which result in such bodily injury to any
person as is likely to cause his death or any dangerous
occurrence specified in the Schedule takes place in a
factory.
• the manager of the factory shall forthwith send a
notice thereof by telephone, special messenger or
telegram to the Inspector and the Chief Inspector.

Sub rules (2);

• When any accident or any dangerous occurrence
specified in the Schedule, which result in the
death of any person or which result in such bodily
injury to any person as is likely to cause his
death takes place in a factory notice as
mentioned in sub-rule (1) shall be sent also to
– The District Magistrate or Sub-Divisional Officer.

– The officer in charge of the nearest Police Station, and
– The relatives of injured or deceased person as notified
by him to the Manager.

Sub rules (3);

• The notice so given shall be confirmed by the
manager of the factory to the above mentioned
authorities within 12 hours of the occurrence by
sending to them a written report in the prescribed
– Form No. 22 in case of a bodily injury
– Form No. 23, if it is a case of fire or explosion and
– Form No. 24 if it is any dangerous occurrence
– From No. 23 and 24 shall be submitted in addition to Form
No. 22 if there are bodily injuries.
– Report in Form No. 22 shall be submitted separately for
each person injured.

Sub rules (4);
• When any accident or dangerous occurrence specified in the Schedule
takes place in a factory and it causes bodily injury to any person as to
prevent the person injured from working for a period of 48 hours or
more immediately following the accident or the dangerous occurrence
as the case may be the Manager of the factory shall send a report
thereof to the Inspector in Form No. 22 within 24 hours after the expiry
of 48 hours from the time of the accident or the dangerous occurrence
• Provided that if in the case of an accident or dangerous occurrence
death occurred of any person injured by accident or dangerous
occurrences, after the notices and reports referred to in the foregoing
sub-rules have been sent the manager of the factory shall forthwith
send a notice thereof by telephone special messenger or telegram to
the authorities and persons mentioned in sub-rules (1) and (2)
• And also have this information confirmed in writing 12 hours of the
death.

• Provided further that, if the period of disability from working for

48 hours or more referred to in sub-rule (4) does not occur
immediately following the accident, or the dangerous occurrence
but later on, or occurs in more than one spell, the report
referred to shall be sent to the Inspector in the prescribed Form
No. 22 within 24 hours immediately following the occurrence
when the actual total period of disability from working resulting
from the accident or the dangerous occurrence becomes 48
hours.

FORM 23
Occurrence Causing Fire or Explosion
THE CHIEF INSPECTOR OF FACTORIES
1. Name of Occupier or (or factory)
2. Address of Works.................
3. Nature of Industry…………….
4. Branch of Department and exact place where the fire broke out
5. On what day and at what time did the fire occur?
6. What caused the fire?
7. What material was burninng
8. Was the fire notice at once, or had, it when discovered, apparently been burning for
some time?
9. How was the fire extinguished?
(Give details of appliances maintained and used)
10. By whom were they used?
11. Was the alarm sent to the Fire Brigade?
12. Give an estimate of loss of the property.
13. By which Insurance Company or companies are the objects in question insured and
for what value?
Signature of Occupier or Manager
Address of ……………

FORM 24
Notice of Dangerous occurrence which does not result in death or bodily injury
1. Name of Occupier (or factory)

2. Address of works where the occurrence occurred.
3. Exact place, branch or department where the occurrence occurred.
4. Date and hour of occurrence.
5. Full description indicating the circumstances under which the occurrence
took place.
6. Extent of damage or loss involved
7. Estimated loss in money.
8. Whether the parts/part involved were insured; if so, give the amount for
which insured and the name of the insurance company?
9. When where the machines or structures involved inspected tested,
required or Certified and by whom?
10. Name of the eye witness, if any, who witnessed the occurrence.
11. Possible reason which may have to be occurrence.
Signature of Manager
Date of Posting

FORM 25
Notice of Poisoning or Disease
1. Name of Factory
2. Address of Factory
3. Address of office or private residence of Occupier
4. Nature of Industry
5. Name of works number of Patient
6. Address of Patient
7. Sex and age of Patient
8. Precise occupation of Patient
8A. Date from which employed on his occupation
9. Nature of poisoning or disease from which Patient is
suffering.
10. Has the case been reported to the Certifying Surgeon?
Date the………..19……….. • Signature …………………..

Safety Module: Accidents, Rev 0.0, Mar 2007 • Manager……………………..
Investigation of Accident

When accident is investigated……..
Following basic questions to be answered
1. Who was injured?

2. Where did the accident happen ?
3. When did the accident happen ?
4. What was the immediate cause and what were the
contributing factors ?
5. Why was the unsafe act or condition permitted?
6. How can this type of accident be prevented ?

Accident investigation
Objective:
 To examine in detail and deep to find out the

causes of accident
 To find out the extent of loss due to accident
 The circumstances that lead to the accident
 To obtain recommendations for prevention of
recurrences of similar accidents.

Accident Investigation- steps
1. Form an investigation team

2. Draw the flow process chart of the work
3. Identify the critical activity
4. Identify the agency
5. Identify the type of accident
6. Identify the nature of work performing
7. Draw the cause effect diagram and Identify the
effect from agency, type Of accident and nature
of work

Accident Investigation- steps
8. Brainstorm for the probable causes of the
identified work
9. Identify the likely causes
10.Confirm likely causes
11.Brainstorm for corrective measures to eliminate
the likely causes
12. Decide the most appropriate solution
13.Implement the solution
14.Make necessary changes in the flow process chart
of the work

Investigation format
1. Age 14.Activity
2. Category of employee 15.Accident deportability
3. Skill 16.Time of accident
4. Sex
17.Hours of accident
5. Marital status
6. Wages 18.Nature of injury
7. Educational qualifications 19.Part of body injured
8. No. Of children 20.Type of accident
9. Total experience 21.Unsafe act
10.Employment
22.Unsafe conditions
11.Overtime
12.PPE – status
13.Language understood

Accident Investigation
Guidelines for Constituting Enquiry Committees
SL. Type of Enquiry Enquiry Other Remarks
NO Accident Committee to committee to members
be appointed be headed by of the
by committee
1 In case of a -- Head of Safety --

non- / Safety officer
reportable of the project/
injury to one station
person
2 Non- AGM-O&M for Not below E-6 Head of Report to

reportable Stations, not connected Safety/ be
injuries upto AGM (Proj) with the Safety submitted
5 persons for projects accident Officer within 7
days

NO Accident Committee committee members
to be to be of the
appointed headed by committee
by
3 Non- AGM Not below Head of
reportable (O&M) for DGM not Safety /
injury to Stations. connected Safety
more than 5 AGM (Proj) with the Officer
persons for accident
Projects.
4 All reportable AGM Not below Head of Report to
accidents (O&M) for DGM not Safety/ be
except Stations. connected Safety submitted
amputation / AGM (Proj) with the Officer within 15
Disablement for accident days
Projects.

NO Accident Committee committee members of
to be to be the
by
5 All Head of Not below 1. One Report to
reportable Project/ DGM not Executive at be
accidents Station connected E-6 level from submitted
causing with the other Project within 15
major accident 2. Head of
injuries like Safety/
amputation Safety Officer
6 Accident Head of Not below 1. One Exec. Report to
causing Project/ AGM from at E-6 level be
Fatal injury Station other from other submitted
to One project/ Project within one
person station of 2. Head of month
the region Safety/
Safety Module: Accidents, Rev 0.0, Mar 2007 Safety Officer
NO Accident Committee to committee members
be appointed to be of the
by headed by committee
7 Accident ED- Region Not below 1. One Report to
causing AGM from DGM from be
Fatal other the submitted
injury to project/ Project / within one
One station of Station month
person the 2. Head of
but region / Safety/
causing Regional Safety
injuries to HQs. Officer
number of
3.
persons
SM(Safety)
Corp.
Centre.

NO Accident Committee committee members of
to be to be the
by
8 Accident D (HR) / GM of 1. One Exec. Report to
causing CMD other at AGM/DGM be
Fatal project/ level from the submitted
injuries to station / Project within one
more than Region / 2. Head of month
One Corp. Safety/
person Centre Safety Officer
3. GM(R&R
and Safety)
4. Any other
expert/
member if
necessary
Calculation Of Accident Rate
1.FREQUENCY RATE
NO.OF INJURIES×106
F=----------------------------------------------------------
TOTAL WORK HOURS OF EXPOSURE
2. SEVERITY RATE
NO.OF DAYS LOST×106

S=----------------------------------------------------------
TOTAL WORK HOURS OF EXPOSURE

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Accident

Safety Module: Accidents, Rev 0.0, Mar 2007

Safety Module: Accidents, Rev 0.0, Mar 2007

Whether accidents in factories are to be

Safety Module: Accidents, Rev 0.0, Mar 2007

Safety Module: Accidents, Rev 0.0, Mar 2007

Is it necessary to have a safety committee?

Safety Module: Accidents, Rev 0.0, Mar 2007

• Is it compulsory that all workers in a factory are to

Safety Module: Accidents, Rev 0.0, Mar 2007

Why Accidents are to be Reported ?

• Minor injuries occur in more numbers than serious injuries and

Safety Module: Accidents, Rev 0.0, Mar 2007

• Prompt report of accidents & dangerous occurrences

Safety Module: Accidents, Rev 0.0, Mar 2007

1. Refer the injured person to dispensary / first aid

Safety Module: Accidents, Rev 0.0, Mar 2007

Sub:- Accident to Shri/Smt XXXXXX

Shri/Smt XXXXX is referred to hospital for treatment.

The details of the injured and incident are as below:

6. Cause of the accident:

• In case the injured person is taken directly

• The HoD will prepare a detailed report of accident

Safety Module: Accidents, Rev 0.0, Mar 2007

Shri XXXX Employee No. YYYY Designation ZZZ of your dept/

Please expedite Form-I, if it is a work accident.

Medical Officer/Dispensary Incharge

Safety Module: Accidents, Rev 0.0, Mar 2007

Safety Module: Accidents, Rev 0.0, Mar 2007

12. Whether any safety guard/system is by passed:

Safety Module: Accidents, Rev 0.0, Mar 2007

16. Describe briefly how accident occurred:

– In case the injured person is disabled for 48 hrs

– Head of Safety will send the Form-18 to

Safety Module: Accidents, Rev 0.0, Mar 2007

1.Name of the Occupier (or Factory)

Safety Module: Accidents, Rev 0.0, Mar 2007

9.a. Causes or nature of accident or dangerous occurrence

10.Nature or extent of injuries (e.g. Fatal loss of fingers,

Safety Module: Accidents, Rev 0.0, Mar 2007

• I certify to the best of my knowledge and belief the above

• Signature of Occupier or Manager

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• Other Particulars e.g. (fatal)

• In case of fatal accident, information of the accident will be

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Employee’s State Insurance Employee’s : N.A

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b) Name of dispensary /panel doctor elected by the injured person.

19. i) Has the injured person died :

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Sl. Nature of injury Type of Due time Signatory

Sub Rule -2;

Sub Rule -3;

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According to Section (88-A),of The Factories Act 1948;

The dangerous occurrence causing any bodily injury

Safety Module: Accidents, Rev 0.0, Mar 2007

According to Section (89) ,of The Factories Act 1948

Sub Rule (1) ;