Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location
  • Date of Incident:

  • Time of Incident:

  • Name of Person Involved:

  • Company No:

  • Age:

  • Occupation:

  • Department:

1.TYPE OF INJURY

1.1. Injury / Incident Classification

  • Clinic Assistance

  • First Aid Assistance

1.2. Part of Body Affected:

  • Neck

  • Eye

  • Head

  • Back

  • Arm

  • Hand

  • Fingers

  • Leg

  • Feet

  • Other

  • undefined

1.3. Side:

  • Left

  • Right

  • Both

Finger injuries:

  • Thumb

  • Index

  • Middle

  • Ring finger

  • Small Finger

1.4. Effect on person:

  • Sprain

  • Wound

  • Fracture

  • Electric Shock

  • Burns

  • FB Eye

  • Amputation

  • Other

2. INCIDENT DESCRIPTION: (BRIEF)

  • undefined

3.1. CAUSE OF INCIDENT

  • Unsafe Act

  • Unsafe Conditions

  • Accident

  • Negligence

3.2. RESULT

  • Fit to resume work

  • Sent to Clinic

  • Send Home

  • Temporarily Disabled

  • Name & Surname of First Aider

  • Signature:

  • Name & Surname Injured Person

  • Signature:

  • Date:

REFUSAL TO ACCEPT FIRST AID AND/ OR MEDICAL TREATMENT:

  • Name & Surname Team Leader

  • Signature

  • Date

  • Name & Surname SHE REP

  • Signature

  • Date

  • Name & Surname (HOD)

  • Signature

  • Date

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