FORMAT NO.
: TSF - 001
REPORT OF ACCIDENTS AND DANGEROUS OCCURRENCES
(To be filled by the site Supervisor)
1. Name of the project/ work : Tata steel Mines – Noamundi
2. Location of project or mines Novamundi
Mines…………………………………………………..
3. Stage of construction work: …………………………………………………
4. Particulars of Employer
(a) Main contractor firm/Co: TPL (b) Sub-contractor's particulars:
Name: ……………………………. Name: …………………………
Address: …………………………. Address: ………………………
Phone Nos.: ……………………… Phone Nos.: …………………….
Nature of Business: ……………. Nature of Business: …………….
5. Particulars of injured person:
(a) Name…………………………………………………………..
(First) (Middle) (Surname)
(b) Home address: ………………………………………………
……………………………………………………
…………………………………………………...
(c) Occupation : ………………………………………………….
(d) Status of the worker
Casual Contract Permanent
(e) Sex: Male / Female : …………… (f) Age : ……………
(g) Experience : ………………
(h) Marital status: Married/ Unmarried/ Divorced : ………………
6. Particulars of Accident
(a) Exact place where accident occurred : ………………………..
(b) Date : …………………. (c) Time : ………………
(d) What the injured person was doing at the time of accident?
(e) Weather condition at the time of accident :
(f) Tenure of employment with the contractor for this particular job?
(g) Particulars of equipment/ machine/ tool used for the work assigned &
condition of the same after the accident occurred :
(h) Brief description of the accident :
TSF - 001 Rev.0 15.06.2011 Page 1 of 3
FORMAT NO. : TSF - 001
REPORT OF ACCIDENTS AND DANGEROUS OCCURRENCES
(To be filled by the site Supervisor)
7. Nature of injuries
(a) Fatal
(b) Non-fatal
(c) If non-fatal, state precisely the nature of injuries
(Describe in detail the nature of injury, for instance fracture of right arm, sprain, etc.)
(d) First Aid: Given: Not given:
(e) If not, given, furnish the reasons :
(f) Name and designation of the person by whom first aid was given :
(g) If admitted to hospital :
Name of the hospital :
Address of the hospital :
Phone No.:
Name of the Doctor :
8. Mode of transport used to carry the injured :
Ambulance Truck Tempo Taxi Private car
9. (a) How much time was taken to shift the injured person?
If very late, state the reasons :
(b) How the reporting was made?
Telephone Telegram Special Messenger Letter
(c) Who visited the accident site first and what action was proposed by
him?
(d) What are the actions taken for the investigation of the accident by the
employer? ( Describe about photographs/ video film/ measurements taken etc.)
10. Particulars of the persons given witness:
Name Address Occupation Temporary/Permanent
(If employed)
1)
2)
3)
4)
TSF - 001 Rev.0 15.06.2011 Page 2 of 3
FORMAT NO. : TSF - 001
REPORT OF ACCIDENTS AND DANGEROUS OCCURRENCES
(To be filled by the site Supervisor)
11. Additional particulars in case of fatal accident :
a) Date: b) Time:
c) Whether registered with building and other construction workers welfare
board? If yes, give Registration No.:
12. Additional particulars in case of Dangerous Occurrences as covered under
the Regulation No. (give details)
(a) collapse or failure of lifting appliances, hoist, conveyors etc.
(b) collapse or subsidence of soil, any wall, floor, gallery etc.
(c) collapse of transmission towers, pipeline, bridges etc.
(d) explosion of receiver, vessels etc.
(e) fire and explosion
(f) spillage or leakage of hazardous substances
(g) collapse, capsizing, toppling or collision of transport equipment
(h) leakage or release of harmful toxic gases at the construction site
(i) failure of lifting appliance, loose gear, hoist or building and other
construction work machinery, transport equipment etc.
13. Certificate from the Employer or authorized signatory.
I certify that to the best of my knowledge and belief, the above particulars are
correct in every respect.
Place : Signature :
Date : Designation :
cc: Forwarded to the following for information and follow-up action:
1)
2)
3)
Note: If more than one person is involved in the accident, then for each person, information is to be filled-
up in separate forms
TSF - 001 Rev.0 15.06.2011 Page 3 of 3
