Title Page
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Reporting Date
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Prepared by
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Location
General Information
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Name of Person Involved in Incident (Last Name, First Name)
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Position - Organization (e.g. RSM - Commercia CP)
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Vehicle Details - Vehicle Type, Plate Number/Conduction Sticker (e.g. Toyota Hi-lux, XXX123)
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Date & Time of Incident (Estimate)
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Location of Incident
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Line Manager (Last Name, First Name)
Incident Details
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HSE Incident Classification (Select all applicable)
- Motor Vehicle Incident
- Fatality
- Lost Day Work
- Non Lost Day - Med Treatment
- First Aid Injury
- Illness - Adverse Reaction
- Distribution
- Environmental Release
- oss, Non-Injury
- Security
- Prosecutions or Fines
- Other Occurence (Near Miss, Safety Observation)
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Driving Golden Rules Violation (Select None or All applicable)
- None
- Use of Mobile Phone
- Not Wearing Seat Belt
- Impaired Driving (Alcohol, Drugs, Fatigue)
- Not Compliant to Speed Limits
- Not Reporting within 24 hours
- Tire Condition
- No or Incomplete Airbags
- No ABS (Anti-lock Braking System)
- No Rearview Mirrors
- PMS/Maintenance
- Hired Vehicle not Inspected Before Trip
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Driver wearing seatbelt?
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What was your speed limit when the incident occurred? (i.e., 60kph)
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What was the environmental conditions (weather, lighting, etc) at the place where the incident occurred?
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Did you have any alcohol prior to the incident?
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What type of alcohol did you have and how much did you drink? (e.g. Beer - 2 bottles)
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Was there any third-party injured during the incident?
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Describe what happened to the third-party who was injured?
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Did you receive any first aid treatment after the incident?
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Describe what kind of first aid treatment did you receive.
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Did you require any additional medical tests after the incident?
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List down what kind of medical or laboratory tests performed after the incident.
Incident Description
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Describe in detail what transpired before, during & after the incident.
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Include pictures here of the incident (if available).
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After filling up the form, please e-mail the form to PH.HSE@syngenta.com.
Confirmation Page
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Please confirm that the details in this report are complete and accurate.
