Name of Person Involved in Incident (Last Name, First Name)
Position - Organization (e.g. RSM - Commercia CP)
Vehicle Details - Vehicle Type, Plate Number/Conduction Sticker (e.g. Toyota Hi-lux, XXX123)
Location of Incident
Line Manager (Last Name, First Name)
- Motor Vehicle Incident
- Lost Day Work
- Non Lost Day - Med Treatment
- First Aid Injury
- Illness - Adverse Reaction
- Environmental Release
- oss, Non-Injury
- Prosecutions or Fines
- Other Occurence (Near Miss, Safety Observation)
- 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
- Hired Vehicle not Inspected Before Trip
Driver wearing seatbelt?
What was your speed limit when the incident occurred? (i.e., 60kph)
What was the environmental conditions (weather, lighting, etc) at the place where the incident occurred?
Did you have any alcohol prior to the incident?
What type of alcohol did you have and how much did you drink? (e.g. Beer - 2 bottles)
Was there any third-party injured during the incident?
Describe what happened to the third-party who was injured?
Did you receive any first aid treatment after the incident?
Describe what kind of first aid treatment did you receive.
Did you require any additional medical tests after the incident?
List down what kind of medical or laboratory tests performed after the incident.
Describe in detail what transpired before, during & after the incident.
After filling up the form, please e-mail the form to PH.HSE@syngenta.com.