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Flush Report - Template

This accident report summarizes a workplace injury that occurred at a Branch location. It provides details of the accident such as the type of injury, who was injured, and the date and location of the accident. The report also analyzes the potential causes of the accident related to worker behavior, equipment, and management practices. Finally, it outlines countermeasures implemented in response, including assigning a person in charge of each action and target dates for completion.

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438 views1 page

Flush Report - Template

This accident report summarizes a workplace injury that occurred at a Branch location. It provides details of the accident such as the type of injury, who was injured, and the date and location of the accident. The report also analyzes the potential causes of the accident related to worker behavior, equipment, and management practices. Finally, it outlines countermeasures implemented in response, including assigning a person in charge of each action and target dates for completion.

Uploaded by

vfuntanilla
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Accident Report for Branch Issue date Date that this document was published

Format A Responsible Manager Site Manager Name

Safety Leader HSSE Manager Name

I. Summary of Accident II. Cause of Accident (aspects of worker's behavior, equipment and management etc.)
Type of the accident

Fatal accident

Lost Work Day (LWD) accident

Non-Lost Work Day (LWD) accident

Property damage

Nature of the accident

Year/Month/Day, Time DLR Name


III. Implemented Countermeasures
Date of Accident
Accidents Occurred Area Countermeasure Person in charge Target Date

Age Job Classification Length of Work Experience


Sufferer

Injury Diagram Outline of the accident

Degree of injury/damage
(Lost working days)

Injury/Damage

Please mark X to the corresponding body


part(s) got injured.

FRONT BACK

Sketch and Photos of countermeasures

Right Hand Left Hand


IV. Distributor Advise / Action
Date

PIC HSSE Manager

Right Foot Left Foot


1. Share this accident information to our all DLR/Branch.
2. Making KYT questions (include this accident) and hold the KYT Competition.

1. SOP: Exist or not exist □　Exist □　Not Exist


SOP
2. SOP: Followed or not followed □　Followed □　Not followed

If an accident occurred, please issue the Flush Report to Distributor within 24 hours.

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