Incident report

• Type of incident

  Select Workplace injury Property damage Road traffic accident Near miss Dangerous occurrence Fatal

  • Workplace injury
  • Property damage
  • Road traffic accident
  • Near miss
  • Dangerous occurrence
  • Fatal

• Location of incident

• Date & time of incident

  Date

• Reporting person

Particulars of injured person (if any)

• Name

• NRIC / FIN No.

• Date of birth

  Date

• Country of origin

• Occupation

• Type & area of injury

Hospitalised

• Date admitted

  Date

• Date Discharged

  Date

• No. of days

Medical Leave

• Start date

  Date

• End Date

  Date

• No. of days

Light Duty

• Start date

  Date

• End date

  Date

• No. of days

Machinery Involved (if any)

• Type / Model

• Distinctive No.

• Certifications

  Yes

  No

  N/A

• Date of last maintenance

  Date

• Machinery condition

  Good

  Fair

  Poor

  N/A

Incident overview

• Description of incident

• Root cause of incident

  Select Personnel Equipment Method Environment Management

  • Personnel
  • Equipment
  • Method
  • Environment
  • Management

• Details of root cause

• Corrective actions & preventive actions

  Yes

  No

  N/A

• Details of corrective & preventive actions

Prepared by

• Name & sign

  Sign

• Designation

Reviewed by

• Name & sign

  Sign

• Designation

Approved by

• Name & sign

  Sign

• Designation