PPL – HSE / FM / IIR / 01Rev 01

INCIDENT REPORTING FORM (IR 01)Dept. / Field / Location: Area:

FATALITY LTI I RWC ACCIDENT (e.g. MINOR INCIDENT / FIRST AID)

NEAR MISS PROPERTY DAMAGE / FIRE / DAMAGE TO ENVIRONMENT

Date of Incident: Time: Reported by:

Name of affected: Employee No: MPT Non MPT

Designation: Department:

Temporary / Permanent / Contract Labor Authorized to perform the task : YES NO

Was task supervised : YES NO Occurrence of Not at Work During overtime Entering or leaving area / office

Incident Performing job alone Performing job in group (Tick one) Brief Description of Incident:

Witnesses : 1) 2) 3)

NATURE OF INJURY

Eyes

Face / Head / Neck

Arms

Hands

Legs

Feet

Trunk

Internal

Back

Others

CLASSIFICATION OF INCIDENT

Design or Layout Equipment failure Construction Work System of work

method of operation Operational

conditions Supervision Training Guarding Maintenance Fire Explosion Gas Leak Oil / Chemical Spill Others

POSSIBLE CAUSE (s) OF INCIDENT

Caught in /on/between Striking against/struck by Motor vehicle accident Injured while handling, lifting or carrying Slips, Trips or falls Overexertion/strain / position of person Foreign Bodies/Objects Trapped by something collapsing or overturning Drowning or asphyxiation Animal/Insect cases Contact with sharps Use of hand tools Thermal/chemical burns Exposure to fire Exposure to an explosion Contact with electricity or an electrical discharge Workplace violence Failure to wear PPE Deficiency of knowledge Personal Factors Other kind of accidents

Treatment Provided:

Sent back to work Sent to Hospital Sent Home

Referred to Site Doctor Not Applicable

Immediate Corrective actions:

Sectional Head: Name & Signature

Date:

Location Incharge: Name & Signature

Date: Comments:

All incidents must be reported to HSE at HO within 24 hrs on IR 01. Investigation report to be generated within 5 days on IR 03 from the date of incident. Near Miss incidents are not required to report on IR 03, except on directives of concerned Dept. Head / Field / Location Incharge / HSE

Dept. HO based on severity and nature of incident.