ACCIDENT / INCIDENT

REPORT
HEALTH & SAFETY
MANAGEMENT SYSTEM
Page 1 of 4
HSE-FORM NO.-REV
HSE-F102-0
Effective date !.4."#14
1. GENERAL INFORMATION REF NO: PL/ACC/ /
PACKAGE RUNNING NO.
CONTRACTOR :
SUB CONTRACTOR :
DATE OF REPORT :
DATE OF ACCIDENT :
TIME OF ACCIDENT :
LOCATION :
2. CATEGORY OF ACCIDENT / INCIDENT
RISK CATEGORY:
Fatality = Lost of life withi ! "e!# of !$$i%et& Total Write Off $
%&'ecove'a()e
Major I'(#ies = I##e)e#si*le& Major *'ec+age , Lo-- $ .RM"#/
Mior I'(#" = Re)e#si*le& Minor Re0ai' , Lo-- $ 1 RM"#/ 2
+. FATAL3TY
,.
4O53LY 3N6%RY
-. 5AMAGE TO PROPERTY FATAL / TOTAL !RITE OFF
.. O77%PAT3ONAL 53SEASE MA"OR
/. O77%PAT3ONAL PO3SON3NG MINOR
0. NEAR M3SS NEAR MISS
1. THEFT
#. TASK AND ACTI$ITY AT T%E TIME OF ACCIDENT / INCIDENT
&. !ITNESS 'IF ANY(
NAME POSITION I2C NO.
/. $ICTIM)S DETAIL 'IF ANY(
Na8e Po-itio&
I.C. No. 2 Pe#3it No. Ma'ita) Stat9-
A4e Natio&a)it:
CIDB G#ee C!#% 2
NIOS5 Co(6o No.
7(!lifi$!tio
8o#9i4 E:6e#ie$e
ACCIDENT / INCIDENT
REPORT
HEALTH & SAFETY
MANAGEMENT SYSTEM
Page " of 4
HSE-FORM NO.-REV
HSE-F102-0
Effective date !.4."#14
*. SE$ERITY + MEDICAL TREATMENT ,NDERTAKEN
-. DESCRI.E IN DETAIL %O! T%E ACCIDENT OCC,RRED
/. CAS,AL FACTORS0 E$ENTS AND CONDITION T%AT CONTRI.,TED TO
T%E ACCIDENT
ACCIDENT / INCIDENT
REPORT
HEALTH & SAFETY
MANAGEMENT SYSTEM
Page ; of 4
HSE-FORM NO.-REV
HSE-F102-0
Effective date !.4."#14
1. STATEMENTS FROM T%E PERSON'S( AT T%E SCENE OF ACCIDENT
'!ITNESS(
12. PROPOSED CORRECTI$E ACTION
ACCIDENT / INCIDENT
REPORT
HEALTH & SAFETY
MANAGEMENT SYSTEM
Page 4 of 4
HSE-FORM NO.-REV
HSE-F102-0
Effective date !.4."#14
11. COMMENTS .Y PRO"ECT MANAGER
12. ADDITIONAL INFORMATION ATTAC%ED ARE:
!. POLICE REPORT
*. LOCATION PLAN OF T5E ACCIDENT 2 INCIDENT
$. SKETC5 2 DIGRAM
%. ACCIDENT P5OTOGRAP5
e. STATEMENT FROM 8ITNESS
1#. !E %ERE.Y CONFIRMED0 ALL T%E INFORMATIONS
CONTAINED IN T%IS ACCIDENT IN$ESTIGATION REPORT IS TR,E
Pr34ar35 .y: A44ro635 .y:
N!3e : N!3e :
Desi4!tio : Desi4!tio : P#o'e$t M!!4e#
Si4!t(#e : Si4!t(#e :
D!te : D!te :
Not3:
a. Det!ile% A$$i%et I)esti4!tio #e6o#t sh!ll *e s(*3itte% to CRCC withi .; ho(#s !fte# !$$i%et 2 i$i%et o$$(##e%.
7. A$$i%et i)esti4!tio #e6o#t sh!ll *e 6#e6!#e% *" !$$i%et i)esti4!tio te!3 whi$h $osist of P#o'e$t M!!4e#< Site
e4iee#< $o36etet S!fet" Offi$e# o# site s(6e#)iso# !t wo#96l!$e.
8. A$$i%et i)esti4!tio #e6o#t sh!ll *e 6#e6!#e% *" P#i$i6le s(* Cot#!$to# !$$i%et i)esti4!tio te!3 !%
#e6#eset!ti)e f#o3 ite#3e%i!te s(* $ot#!$to# =wo#9 $ot#!$to#>.
5. CRCC will ot hesit!te to #e'e$t i$o36lete !$$i%et 2 i$i%et #e6o#t if the ifo#3!tio $ot!ie% is ot !$$(#!te o#
6#e6!#e% *" thi#% 6!#t".
3. This i$i%et sh!ll *e #e$o#%e% ito S!fet" Noti$es Re$o#% ? A$$i%et 2 I$i%et '%SE9F12-92(