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Accident Investigation Report Rev 00

The document details an accident investigation report template. It includes sections for details of the injured person, location and time of the accident, description of what happened, machine involved, probable causes, witness details, medical report, and actions to take in case of an accident.

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Arunava Basak
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202 views

Accident Investigation Report Rev 00

The document details an accident investigation report template. It includes sections for details of the injured person, location and time of the accident, description of what happened, machine involved, probable causes, witness details, medical report, and actions to take in case of an accident.

Uploaded by

Arunava Basak
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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ACCIDENT INVESTIGATION REPORT

Name of the Injured _____________________

ESI No: ________________________ Designation: _____________ Ticket No. ______

Place of accident: __________________

Date of accident _____________ Shift ________________ Time __________ Age ________

Detailed Description of the accident including what the injured person was doing and how he got injured
(If Space is inadequate use rear side of this form)

Caused by which Machine and which part: __________________

Machine operated by Mechanical / Electrical power: _____________________

Probable Causes of Accident/ Injury/ Property Damage

Unsafe Conditions Unsafe Acts


 Defective Agency / Part Operating w/o Authority
 Unguarded Agency/ Part Failure to secure the job/ wear PPE
 Improperly guarded Agency/ Part Operating at Unsafe Speed
 Unsafe Storage, Piling Making Safety device inoperative
 Bad Housekeeping` Using Equip/ Tool etc. Unsafely
 Unsafe Layout, Procedure etc Using Defective/ Wrong Equip /
 Improper Lighting Tool/ PPE etc.
 Improper Ventilation Unsafe Handling
 Leakage / Presence of Obnoxious Taking Unsafe Posture / Position
 Fumes / Vapours / Gases/ Dust Failure to examine machine/ equip
Etc. before start of work

WITNESS: Name Roll No SUPERVISOR: SITE IN-CHARGE

1. Name: Name:

2. Sign: Sign:
TO BE FILLED BY MEDICAL CENTRE

Location of Injury:

Nature of Injury:

Wounds: Laceration, Contusion, Incised, Puncture

Eyes: Foreign Body, Burn Corrosive

Skin Burns: Heat, Chemical, Friction

Fracture:

Sprain:

Exposure to Gases: Nausea, Dizziness, Irritation

Miscellaneous:

Given First aid: Yes No

Went Back to Work:

Sent to Hospital:

Name of Hospital:

Minor Accident

Major Accident

Whether likely to be disabled for more than 48 hrs: Yes No

Doctor/ First aider Name:

Sign: Date:

________________________________
Signature of HSE

Note: This report should reach HSO with in 48 Hrs of the Occurrence of the accident.
WHAT TO DO INCASE OF ACCIDENT

Accident Occurs

No
Person Injured

Yes

Rescue injured person

Given First aid/ taken him to the Hospital

Inform Clients Management

Send accident report in the format provided to the


HSO within 48 Hrs of the Occurrence. Extend the required
help to concerned client in reporting the accident
to regulating authorities

Investigate the accident – find root

Take Corrective and Preventive action

Follow up Insurance Claims in case of injury


Or Property Damage

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