P. O. Box: 261032, Dubai, U.A.ETel: 04 – 2821182, Fax: 04 - 2820215

E-mail: dynatechsafety@eim.ae

ACCIDENT / INCIDENT / NEAR MISS REPORT

Contractor :

Project :

Accident Incident Near Miss

Date of Occurrence: Time of Occurrence:

DETAILS OF INJURED PERSONS:

Name Card No. Part of the body injuredFirst Aid / Hospital

Treatment

DETAILS OF MACHINERY / VEHICLES INVOLVED:

Sl.No. Details of Machinery / Vehicle Details of Driver / Operator

1

2

3

WITNESS:

Sl.No. Name Card No. Signature

1

2

DETAILS OF PROPERTY DAMAGE:

DETAILS OF EXACT LOCATION:

Page 1 of 2 Form # DSSS/S/04

P. O. Box: 261032, Dubai, U.A.ETel: 04 – 2821182, Fax: 04 - 2820215

E-mail: dynatechsafety@eim.ae

ACCIDENT / INCIDENT / NEAR MISS REPORT

BRIEF DESCRIPTION / DETAILS OF THE ACCIDENT / INCIDENT / NEAR MISS:

CONTRIBUTORY FACTORS:

Unsafe Condition : YES / NO Unsafe Acts: YES / NO

Lack of training / Supervision : YES / NO Bad House Keeping : YES / NO

Environmental Condition (Wind, rain, etc..): YES / NO

State of equipment (Faulty breaks, damaged lifting gear etc..): YES / NO

Other:

CORRECTIVE/ PREVENTIVE ACTIONS:

Required: YES / NO Form # DSSS/S/003 enclosed: YES / NO

Report Prepared By : Name: Signature: Date:

Manager In-charge : Name: Signature: Date:

Cc: Personnel Department (for accident/ incident only) Cc: Safety

Department Govt. Authorities

SAFETY DEPARTMENT – Investigation details / action to be taken:

Report Closed By - Name:Signature: Date:

Attachments:

Photographs……………Nos.

Police Report

Other………………………..

Cc: Manager In-charge, Personnel Department (for accident / incident only) (Page 2 of 2) Form # DSSS/S/04

P. O. Box: 261032, Dubai, U.A.ETel: 04 – 2821182, Fax: 04 - 2820215

E-mail: dynatechsafety@eim.ae