Title Page
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Site conducted
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Client
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Injured / Affected Person
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ID No: of Injured / Affected Person
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Date of Incident
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Name of Investigator/Inspector
A. RECORDING OF INCIDENT
Part of body affected (Multiple Choices can be made)
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- Head or Neck
- Eye
- Trunk
- Finger
- Hand
- Arm
- Foot
- Leg
- Internal
Effect on person
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- Sprains or strains
- Contusion or wounds
- Fractures
- Burns
- Amputation
- Electric shock
- Asphyxiation
- Unconsciousness
- Poisoning
- Occupat. Disease
Expected period of disablement
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- 0-13 days
- 2-4 weeks
- >4-16 weeks
- >16-52 weeks
- >52 weeks or permanent disablement
- Killed
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Description of occupational disease
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Machine /process involved /type of work performed/exposure**
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Please add Photo's of the incident
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Was the incident reported to the Compensation Commissioner and Provincial Director
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Was the incident reported to the police?*
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SAPS office and reference
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*to be completed in case of a fatal incident
**In case of a hazardous chemical substance, indicate substance exposed to
B. INVESTIGATION OF THE ABOVE INCIDENT BY A PERSON DESIGNATED THERETO
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Name of investigator
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Date of investigation
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Designation of investigator
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Short description of incident:
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Suspected cause of incident:
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Recommended steps to prevent a recurrence:
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Signature of Investigator
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Select date
C. ACTION TAKEN BY EMPLOYER TO PREVENT THE RECURRENCE OF A SIMILAR INCIDENT
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ACTION TAKEN BY EMPLOYER TO PREVENT THE RECURRENCE OF A SIMILAR INCIDENT:
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Signature of employer:
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Select date
D. REMARKS BY HEALTH AND SAFETY COMMITTEE
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Remarks
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Signature of Chairman of Health and Safety Committee
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Select date
