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Accident - Incident Report Form

The document is an Accident/Incident Investigation and Risk Assessment Report template, designed to collect essential information regarding workplace incidents. It includes sections for details such as the type of incident, location, witnesses, nature of the accident, involved personnel, and corrective actions. The report aims to ensure proper documentation and preventive measures to avoid future occurrences.

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Claudel Bea Opaon
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84 views5 pages

Accident - Incident Report Form

The document is an Accident/Incident Investigation and Risk Assessment Report template, designed to collect essential information regarding workplace incidents. It includes sections for details such as the type of incident, location, witnesses, nature of the accident, involved personnel, and corrective actions. The report aims to ensure proper documentation and preventive measures to avoid future occurrences.

Uploaded by

Claudel Bea Opaon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

COMPANY LOGO

ACCIDENT / INCIDENT INVESTIGATION AND RISK


ASSESSMENT REPORT

Fatal:
Medical Treatment:
First Aid Case:
Property Damage:
Near miss: Other :

DATE PREPARED:
TYPE OF INCIDENT/ACCIDENT:
PROJECT LOCATION:
DATE/ TIME OF INCIDENT OR ACCIDENT:
NAME OF WITNESSES: 1.
2.
3.
4.
5.
ACTIVITIES ON SITE DURING THE ACCIDENT:
TRABAHONG GINAGAWA NG MAGANAP ANG INSIDENTE

LOCATION OF INCIDENT/ ACCIDENT:


LUGAR NA KINAPANGYARIHAN NG INSIDENTE/ AKSIDENTE

NAME OF SAFETY OFFICER ON SITE:


PANGALAN NG SAFETY OFFICER
WHEN IS THE INCIDENT / ACCIDENT HAPPENED:
KAILAN NAGANAP ANG INSIDENTE / AKSIDENTE

NATURE OF INCIDENT/ ACCIDENT:


ANO ANG PANGYAYARI

HOW THE INCIDENT / ACCIDENT HAPPENED:


PAANO NAGANAP ANG INSIDENTE / AKSIDENTE

PERSON INVOLVED:
TAONG NADAMAY SA PANGYAYARI
DAMAGED EQUIPMENT:
ANO ANG GAMIT NA NASIRA

EQUIPMENT INVOLVED:
ANONG EQUIPMENT ANG NASIRA

ASSESSMENT ACTION:
ANO ANG GINAWA MATAPOS ANG PANGYAYARI

CORRECTIVE ACTION:
ANO ANG MGA DAPAT GAWIN PARA HINDI NA MAULIT ANG MGA PANGYAYARI
PREVENTIVE MEASURE:
ANO ANG HAKBANG NA GAWIN PARA MAIWASAN ANG AKSIDENTE

SKETCH / DRAWING

*Add separate sheet if the available space provided is not enough.


Reported by: Noted by:

Name & Signature: Name & Signature:


Position : EHS Officer Project Manager: Project
Manager

*Incident – Any intended or unintended event, occurrence or happening involving


company personnel or property that results to injury or damage to property (Ex. Theft
within the company promises, personal threats/fights, Arson affecting company
property, etc.)

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