Delta Company Ltd.

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Instructions: The investigator must fill all fields in full and then re-send a copy of the front page to safety department within 24 hours, and then send the completed investigations' final report to the Department of Industrial Security within 72 hours.

Employee General Information:

• Name:

• Position:

• Badge Number:

• Iqama Number:

• Location:
  Address

• Accident Date:

  Date

• Reporting Date:

  Date

• Overtime

  Yes

  No

• No. Of overtime hours

• Shift Time Start:

  Select AM PM

  • AM
  • PM

• Task:

• Experience:

• Investigation Date:

  Date

• Supervisor Name:

• Add signature

  Sign

• Select date

  Date

• Manager Name:

• Add signature

  Sign

• Select date

  Date

Near-miss, Loss Accident, Lost Time Injuries Details:

• Loss Level

  Select No equipment damage Less than 500 SR More than 5000 SR loss Major damage Lost Time Injury

  • No equipment damage
  • Less than 500 SR
  • More than 5000 SR loss
  • Major damage
  • Lost Time Injury

• Estimated cost of losses in SR.

• Possibility of Recurrence

  Select Low Medium Medium-high High

  • Low
  • Medium
  • Medium-high
  • High

• Expected Loss

  Select Low Medium Medium-high High

  • Low
  • Medium
  • Medium-high
  • High

• Injury Severity Level

  Select First aid Minor Lost Time Injury Disability Injury No Medical Treatment Required Other

  • First aid
  • Minor
  • Lost Time Injury
  • Disability Injury
  • No Medical Treatment Required
  • Other

• Accident Type

  Select Near-miss Accident Property Damage Vehicle Accident (Motor Vehicle Accident) Fire Occupational Injury Non Occupational Injury Other

  • Near-miss
  • Accident
  • Property Damage
  • Vehicle Accident (Motor Vehicle Accident)
  • Fire
  • Occupational Injury
  • Non Occupational Injury
  • Other

• Vehicle type:

• Vehicle no.

• Plate no.

• No. Of vehicle involved:

• Basic Causes:

  Select Improper speed for existing condition Delayed perception Faulty evasive action Improper backing Wrong lane position Improper turning Sudden movement Following too closely Improper parking Vehicle defect Other faulty part Traffic signal violation Other

  • Improper speed for existing condition
  • Delayed perception
  • Faulty evasive action
  • Improper backing
  • Wrong lane position
  • Improper turning
  • Sudden movement
  • Following too closely
  • Improper parking
  • Vehicle defect
  • Other faulty part
  • Traffic signal violation
  • Other

• Body Parts

  Select Head Nose/mouth/ear Arms Mid back Right leg Right foot Neck Shoulder Right arm Low back Left leg Left foot Forehead Chest Left arm Hips Knees Ankles Eyes Hands Both wrists Hand finger Right hip Right knee Right ankle Right eye Right hand Right hand Right wrist Back Left hip Left knee Left ankle Left eye Left hand Left wrist Upper back Legs Feet Leg Feet Feet fingers Others, specify

  • Head
  • Nose/mouth/ear
  • Arms
  • Mid back
  • Right leg
  • Right foot
  • Neck
  • Shoulder
  • Right arm
  • Low back
  • Left leg
  • Left foot
  • Forehead
  • Chest
  • Left arm
  • Hips
  • Knees
  • Ankles
  • Eyes
  • Hands
  • Both wrists
  • Hand finger
  • Right hip
  • Right knee
  • Right ankle
  • Right eye
  • Right hand
  • Right hand
  • Right wrist
  • Back
  • Left hip
  • Left knee
  • Left ankle
  • Left eye
  • Left hand
  • Left wrist
  • Upper back
  • Legs
  • Feet
  • Leg
  • Feet
  • Feet fingers
  • Others, specify

• Nature of Injury:

  Select Trauma amputation Asphyxia Burn (Heat or chemical) Contusion bruise Wound (laceration/abrasion) Fracture (open/closed) Skin irritation Dislocation Electric shock Heat exhaustion Hernia Inflammation Sprain/strain Multiple injuries Puncture Foreign object Other

  • Trauma amputation
  • Asphyxia
  • Burn (Heat or chemical)
  • Contusion bruise
  • Wound (laceration/abrasion)
  • Fracture (open/closed)
  • Skin irritation
  • Dislocation
  • Electric shock
  • Heat exhaustion
  • Hernia
  • Inflammation
  • Sprain/strain
  • Multiple injuries
  • Puncture
  • Foreign object
  • Other

• Unsafe Conditions:

  Select Inadequate or improper PPE Defective tools/equipment/materials Noise exposure Congestion/ restricted/overcrowded work area Inadequate ventilation Inadequate warning system Fire and explosion hazard Poor housekeeping Hazardous environment Repetitive Radiation exposure High or low temperature exposure Inadequate/excess illumination Other, specify

  • Inadequate or improper PPE
  • Defective tools/equipment/materials
  • Noise exposure
  • Congestion/ restricted/overcrowded work area
  • Inadequate ventilation
  • Inadequate warning system
  • Fire and explosion hazard
  • Poor housekeeping
  • Hazardous environment
  • Repetitive
  • Radiation exposure
  • High or low temperature exposure
  • Inadequate/excess illumination
  • Other, specify

• Describe the unsafe acts (At Risk Behavior) and conditions that existed.

• Describe the unsafe conditions (High Risk Environment)

• Which job factors lead to the unsafe condition. / at risk behavior? Explain.

  Select Inadequate leadership/supervision Inadequate engineering Inadequate purchasing Inadequate maintenance Inadequate tools/equipment Inadequate work standards Wear and tear Abuse or misuse Inadequate ergonomic design

  • Inadequate leadership/supervision
  • Inadequate engineering
  • Inadequate purchasing
  • Inadequate maintenance
  • Inadequate tools/equipment
  • Inadequate work standards
  • Wear and tear
  • Abuse or misuse
  • Inadequate ergonomic design

• What personal factors led to the unsafe act? Explain.

  Select Inadequate capability Lack of knowledge Lack of skill Stress Improper motivation Physical problem

  • Inadequate capability
  • Lack of knowledge
  • Lack of skill
  • Stress
  • Improper motivation
  • Physical problem

• Which. Safety system elements could prevent recurrence or reduce risks? (See attached list of system elements)

• Safety Equipment in Use:

  Select Hard hats Hearing protection Safety shoes Safety goggles Respirators Gloves Fall protection Protective clothing Other, specify.

  • Hard hats
  • Hearing protection
  • Safety shoes
  • Safety goggles
  • Respirators
  • Gloves
  • Fall protection
  • Protective clothing
  • Other, specify.
Witness

• Witness

• Badge No.

• Sketch the conditions of the near miss / accident or attached statements from witnesses or photo if available.

  Drawing

• Picture evidence

  Media

5-Star Safety System Elements

• Control Steps to Prevent Recurrence

Control Steps to Prevent Recurrence

Steps

• Steps

• Assigned to:

• The schedule completion date:

  Date

• The actual completion date:

  Date

Control Steps to Prevent Recurrence

Steps

• Steps

• Assigned to:

• The schedule completion date:

  Date

• The actual completion date:

  Date

• What follow-up actions that have been implemented to monitor the effectiveness of corrective action?

• Date of Completion

  Date

Supervisors or Investigators Note:

• Detective Name:

• Date

  Date

• Signature:

  Sign

• Investigators Note:

• Supervisors Name:

• Date

  Date

• Signature:

  Sign

• Supervisors Note:

• Manager Name:

• Date

  Date

• Signature:

  Sign

• Manager Note:

• Executive Director Name:

• Date

  Date

• Signature:

  Sign

• Executive Director Note:

• VP Name:

• Date

  Date

• Signature:

  Sign

• VP Note:

• Industry Security Department Name:

• Date

  Date

• Signature:

  Sign

• Industry Security Department Note:

• Select date

  Date