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Accident - Incident Report - Form

This incident report documents a safety concern reported by Padraig Ryan, the health and safety manager, for Project 01 located at Europlan Engineering. The report involves an incident but not an accident. No details are provided about the incident, but photographic evidence is attached. The injured person's name is listed but no other details are given. Three immediate corrective actions were taken in response but their details are not stated. The report was prepared by a staff member and reviewed by Padraig Ryan, the project manager.

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111 views3 pages

Accident - Incident Report - Form

This incident report documents a safety concern reported by Padraig Ryan, the health and safety manager, for Project 01 located at Europlan Engineering. The report involves an incident but not an accident. No details are provided about the incident, but photographic evidence is attached. The injured person's name is listed but no other details are given. Three immediate corrective actions were taken in response but their details are not stated. The report was prepared by a staff member and reviewed by Padraig Ryan, the project manager.

Uploaded by

dany
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
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ACCIDENT/ INCIDENT REPORT (Safety Concern)

1. Project Information:
Project Name: Report No. 01.
Project Location: H&S Manager Padraig Ryan

2. Select:
Accident ☐
Incident ☐

3. Information:
Date: Time:
Type: ☐ Fatality ☐ Other (Specify)
☐ Serious Injury
☐ Serious Occupational Illness/Disease
☐ Serious Dangerous Occurrence
☐ Equipment/Property Damage
☐ Major Environmental Incident
☐ Near Miss
☐ Others

Accident/ Incident
Description (Attach
additional pages if Padraig Ryan: XXXXXXXX
required):
XXXXXXXXX

Accident/ Incident
Location on
Site:
Applicable Reports: ☐ Police ☐ Medical ☐ Other
Europlan Engineering
Attached Evidence: ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

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ACCIDENT/ INCIDENT REPORT (Safety Concern)

4. Injury Type based on Immediate Judgment of the Severity :


The actual severity and consequences of the notified based on diagnosis by licensed health care
professional and supported by medical report shall be reported in the incident investigation report.
☐ Injury causing the affected person temporarily unable to perform any regular job or restricted work
activity on a subsequent scheduled workday or shift
☐ Immediate medical treatment of the injured person(s) as an in-patient in a hospital
☐ Medical treatment of the injured person(s) within 48 hours of exposure to a substance
☐ Unknown at the time of reporting
Immediate medical treatment of the injured person(s) for:
☐ fracture ☐ the separation of skin from any underlying tissue
(such as scalping or de-gloving)
☐ loss of a distinct part or organ of body including ☐ electric shock or electrical burn
the amputation of any part of body
☐ loss of consciousness and/or requiring ☐ serious burns due to thermal and chemical agents
resuscitation
☐ a serious head injury ☐ entrapment of a body part in machinery /
equipment / plant
☐ a serious eye injury including loss of ☐ a spinal injury
sight (temporary or permanent)
☐ exposure to a hazardous material ☐ dislocation of joints
☐ penetration injury with a risk of infectious disease ☐ the loss of bodily function
transmission (such as needle-stick
☐ serious laceration ☐ other (Specify)

5. Injured Person’s Personal Details :


In case of an incident with more than one injured person, complete the information for each person using
separate forms.
Name: Occupation:

6. Equipment/Property Damage Details :


Complete.

7. Key Corrections Taken Immediately after the Incident :


Detailed Corrective Actions shall be reported in the incident investigation report.
(Attach additional pages if more space is required).
No. Actions Status
1.
2.
3.

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ACCIDENT/ INCIDENT REPORT (Safety Concern)

Report Prepared by: Reviewed by PM (Manager In


Charge):
Name : XXXXXXX Name : Padraig Ryan
Date: Date:
Signature: Signature:

*Attached Evidence: Photographic.

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