PR1009.07 Vilicom Injured Person Initial Accident report

• Site conducted

  Select

• Department

• Full Name of Employee

• Age

• Conducted on (Date and Time)

  Date

• Full Name of Supervisor / line manager

  Select

• Full name of Project manager

  Select

General Information

• Type of Accident

  Select Personal injury Property loss Others

  • Personal injury
  • Property loss
  • Others

• If asset damage state, the asset ID, extent of damage

• Capture photo of Identification / damage etc

  Media

• Date and time of the incident

  Date
• Location of the incident
  Address

• Were the police called to the accident?

  No

  Yes

• First aid Treatment given?

  No

  Yes

• Treatment given by who?

• Treatment given?

• Are there other people involved?

  No

  Yes

• Person/s involved? Click "Add"

Injured Person

• Capture photo of Identification / injury etc

  Media

• Phone Number

• Email address

• Was hospitalisation require?

  No

  Yes
• Why and please give the hospital address
  Address

Accident Report

• Direct Cause of the Accident: Describe the behaviours and/or conditions that directly caused this incident.

• Circumstances - Describe What Happened, Activity taking place at the time of the accident, How the Event Occurred, Any Equipment, tools, plant Involved, any other Persons involved.

• Weather conditions?

  Select

• Was a vehicle involved?

  No

  Yes

• Capture photo evidence

  Media

• Any lost time?

  No

  Yes

• Please say how much time was lost i.e. hours / days away from work

• Why did the incident happen?

  Select Poorly maintained tools or equipment Poor housekeeping, slippery floor, or tripping hazards Unguarded equipment Crowded work condition Poor storage practices Failure to wear PPE Insufficient lighting or ventilation Cold or hot temperature Others

  • Poorly maintained tools or equipment
  • Poor housekeeping, slippery floor, or tripping hazards
  • Unguarded equipment
  • Crowded work condition
  • Poor storage practices
  • Failure to wear PPE
  • Insufficient lighting or ventilation
  • Cold or hot temperature
  • Others

• Incurred injuries (body part / type of injury)

  Select

• Did the employee leave work because of the accident?

  No

  Yes

• What are the consequences of the accident?

  Select Personal injury Property loss Others

  • Personal injury
  • Property loss
  • Others

• Please specify

• Did you need to see a doctor?

  No

  Yes

• Please explain why and what the advice from the doctor was.

• Where you prescribed and medication that could make you drowsy?

  No

  Yes

• Have you told your line manager about the medication?

  Yes

  No

  N/A

Questions to Consider to Identify any Underlying Causes?

• Did deviation from current systems or processes contribute to the event?

  No

  Yes

• Did staff actions contribute to the event?

  No

  Yes

• Did inadequate staff training/skill contribute to the incident?

  No

  Yes

• Did inadequate staffing resources contribute directly to the incident?

  No

  Yes

• Did poor communication or information contribute to the incident?

  No

  Yes

• Did a malfunction or absence of equipment appear to contribute to the adverse event?

  No

  Yes

• Did controllable environment factors directly affect the outcome?

  No

  Yes

• Are there any uncontrollable external factors truly beyond the organisation's control? Give reasons why.

  No

  Yes

• Are there any other factors that have directly influenced this outcome?

  No

  Yes

Witness/es

• Are there any witness/es?

  Yes

  No

• Witness/es? Click "Add"

Witness

• Full Name

• Phone Number

• Statement

• Signature

  Sign

Completion

• Recommendations to avoid accident recurrence

  Select

• Line manager Full Name and Signature

  Sign

• Project manager full name and signature

  Sign