Loss

  • What type of incident was this?

  • Case Number:

  • Driver Name:

  • Vehicle Registration:

  • Is there a 3rd party involved

  • Has Group Services been notified?

  • Claim Number:

  • If accident has taken place on a public road, has SAPS been notified?

  • AR Number:

  • Is there damage to the vehicle?

  • Description of Damage:

  • Cost of Damage: R

  • Asset Number:

  • Description of Damage:

  • Cost of Damage: R

  • Is this an insurance claim?

  • Has Group Services been notified?

  • Type of work being performed?

  • Specify:

  • Short Description Of Incident (What happened and How?)

  • Has the Manager investigated and found negligence on the part of any employee involved?

  • Reason:

Injury Details

  • Is this a work related incident?

  • Expected Period of Disablement:

  • Nature of Injury:

  • Specify:

  • Accident Type:

  • Specify:

  • Part of Body:

  • Specify:

  • Root Cause Analysis (5 why's)
  • Why: ... (specify your question)

  • Answer:

  • Recommended steps to prevent reoccurance:
  • Action taken by employer to prevent the recurrence of a similar incident:

  • Employee Signature:

  • Safety Rep Signature:

  • Supervisor Signature:

  • Investigator Signature:

  • Group OHS Officer Signature:

  • Safety Committee Chairman:

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