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NIOSH
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INCIDENT REPORT
Revision No : 00
Case No :

ACCIDENT / INCIDENT INFORMATION

General Types of Incident

Incident Date: Time: Safety Injurious
Location: Fatal  Restricted Work 
Department: Section: PTD  First-Aid 
Others (if any): Lost Work Days  Occupational Illness 
Particular of Personnel Involved Non Injurious
Victim’s Name: Fire / Explosion  Vehicle Hazard 
Occupation: Equipment Damage  Oil / Chemical Spill 
Staff No (if any): Consequence Ammonia Release 
Department: Days Lost Time: CNG Release 
NRIC / Passport: Act.Cost (RM): WWTP Discharge 
Employment Period: year month Spill Vol (m³): Public / Security / 
Date of employment Additional Significant Implication/Impact To:
Nationality : Health  Environment 
Contractor (if app): Safety  Productio

Immediate Supervisor:
For Recognition of Initial Report (24 hours Notification) Incident Witnesses
Prepared By: Name 1:
Position: Name 2:
Date: Name 3:
Major/ Minor Accident (for Injurious Incident)
Nature or type of Injury Body Parts Injury details
 Amputation Description of Injury:
 Bruise or Crushing
 Burn or Scald
 Concussion Location of Injury (mark the
 Cut or Open Wound location)

 Dislocation Head
 Exposure Upper Limb
 Foreign Body Lover Limb
 Fracture Treatment Obtained
 Heart / Circulatory condition  First Aid Treatment
 Infection disease  Panel Clinic
 Inhalation  Hospital Casualties
 Internal injury  Hospi
a
l
Ad Nerve System Injury  Other:
mit
ted

 Poisoning
Out come of Injured Person
 Puncture
 Respiratory No of work day lost?
 Skin Disorder  Eye  Organ
 Sprain or Strain  Ear  Teeth Not yet returned to work
 Other  Nose  Brain (Inform Safety & Health
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NIOSH
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INCIDENT REPORT
Revision No : 00
Case No :

Officer)

LIST OF HAZARD CONTRIBUTING TO THE INCIDENT (Type of Contact)

Animal or Insect  Noise  Vehicle 

Biological  Psychological  Machineries 
Chemical  Radiation  Explosion 
Electricity  Slip, Trip Muscular Effort single event 
fall

Powered Hand Tools  Strike on against Object  Vibration 
Hand Tools  Hit by falling object  Others (if any) 
Muscular Effort repetitive  Struck or hit by falling object 
Sharp edge or Needle  Thermal (heat or cold) 

EVENT LEADING UP TO AND DESCRIPTION OF INCIDENT

(What, When, Where, Why, How?) (Explain in full including dates, location, cause and action)

ROOT CAUSE OF THE PROBLEM

GENERAL FAILURE
(Hardware Design of Engineering, Maintenance Management, Procedure, House Keeping, Communication, Training)
Human / Job Factor Machinery / Material Factor

Admin / Management Factor Environmental Factor

IMMEDIATE ACTIONS TAKEN

Action Responsible Start Complete

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NIOSH
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INCIDENT REPORT
Revision No : 00
Case No :

CORRECTIVE ACTION (by HOD Responsible)

Details of Proposed Action

Action to be taken by Date of action to be completed

Signature
ggf

VERIFICATION OF CORRECTIVE ACTION

Details of Verification

Verified by
Verified date
(Safety & Health Officer)
Signature
ggf

VERIFICATION OF CORRECTIVE ACTION EFFECTIVENESS

Details of Effectiveness

Evidence of Effectiveness:-
Effectiveness ………………………………………………………………………...
………………………………………………………………………...
Status Closed Status Open
………………………………………………………………………...
………………………………………………………………...………

Verified by
Verified Date
(Safety & Health Officer)
Signature

SPACE FOR ADDITIONAL INFORMATION, SKETCHES, PHOTO, LOCATION MAP & ETC
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NIOSH
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INCIDENT REPORT
Revision No : 00
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ACKNOWLEDGED BY

Designation Name Signature (for paper reporting) Date

HOD responsible

ESH Manager

Operations Manager