PV Gen Incident Report Form

• Client Name & Site Location

• Conducted on

  Date

• Prepared by

• Personnel

SECTION I

• Date and time of incident

  Date

• Location of the incident

• Describe the incident

• Were there any witnesses

  Yes

  No

  N/A

• Details of witness/es

Incident Category

• Select the appropriate category for the incident:

• Slip, Trip or Fall

• Equipment of Machinery Malfunction

• Hazardous Material Exposure

• Fire or Explosion

• Personal Injury

• Near Miss (incident with potential for harm but no actual injury)

• Other:

  Yes

  No

  N/A

• Details

Person(s) Involved

• Name(s) of the person(s) directly involved in the incident

• Job title(s) of the person(s) involved

• Describe the nature and extent of the injuries, if any

• Describe the treatments provided, if any

Immediate Actions Taken

• Describe the immediate actions taken to address the incident and ensure safety

Contributing Factors

• Were there any contributing factors to the incident?

  Yes

  No

  N/A

• If yes, select the relevant factor

• Inadequate training

• Equipment failure

• Unsafe work conditions

• Human error

• Lack of supervision

• Communication breakdown

• Other:

  Yes

  No

  N/A

• Specify

Investigation

• Will a further investigation be conducted?

  Yes

  No

  N/A

• If yes, specify the person(s) responsible for the investigation

  Yes

  No

  N/A

• Provide any additional details or instructions for the investigation

Preventive Measures

• What preventive measures can be implemented to avoid similar incidents in the future?

Additional Comments

• Is there any additional information or commecnts you would like to include?

Report Filter

• Name

• Job Title / Role

• Contact Details