Internal
Incident Investigation Report
Doc No. 1 / IMS / F / 32 Revision No.0 Date: 01/07/2019
Name of site: – Site Location:
Section Head / Project Manager:
Engineer:
Supervisor:
Safety Officer:
Date & Time of Incident Date & Time of
happened Reporting
Incident Category Type of Incident
(Refer Annexure on Last
(Refer Annexure on Last page)
page)
Body Part Injured Nature of injury
(Refer Annexure on Last
(Refer Annexure on Last page)
page)
Agency
(Refer Annexure on Last page)
Details of Injured Person (IP)
a. Name of IP b. Age (yrs.)
c. Name of Contractor with d. Gender
whom IP was working (Male/ Female / Others)
e. Since when IP is working f. Total experience of IP
with this contractor (Internal + External)
Investigation Team members:
Description of
Incident
(Type of work /
activity, What & how
incident happened,
injury in details with
body part injured)
Prepared & Issued DIVISION
OHS HEAD Authorized By
By HEAD
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Internal
Incident Investigation Report
Doc No. 1 / IMS / F / 32 Revision No.0 Date: 01/07/2019
Cause Analysis
using Cause and
Effect Diagram
(Tick the causes)
Underlying Causes
Root Cause / Most
Probable cause
Corrections
(Immediate action
taken on incident
scenario like, giving
first aid taking IP to
hospital,
communication etc)
Prepared & Issued DIVISION
OHS HEAD Authorized By
By HEAD
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Internal
Incident Investigation Report
Doc No. 1 / IMS / F / 32 Revision No.0 Date: 01/07/2019
Corrective Action
(Action taken on the
identified causes to
prevent the
recurrence of
incident)
Name & Details of
Witness (If any) –
Inputs from
Witness (If any)
Draw a neat sketch of Incident at Site; (If required draw multiple sketches also)
Prepared & Issued DIVISION
OHS HEAD Authorized By
By HEAD
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Internal
Incident Investigation Report
Doc No. 1 / IMS / F / 32 Revision No.0 Date: 01/07/2019
Incident Closure:
1. IP discharged from Hospital on (Date) - Not admitted
2. IP resumed duty on (Date) - 04/10/2024( same day)
3. Total Man-days lost due to incident - NA
4. Direct Cost of Accident - NA
5. HIARO review (HIRA shall be reviewed after every incident)
a. HIARO document number: – Rev. No. Date:
b. Is this activity covered in HIARO? (Please tick) - Yes / No (If No, add the activity
in HIARO)
c. Review Date of HIARO (it should be after incident):
d. Changes done in HIARO: Yes /No/NA
e. Date of HIARO Revision:
f. Description of added/changes done in HIRA:
Remarks by Project Manager –
Signature of Project Manager –
Prepared & Issued DIVISION
OHS HEAD Authorized By
By HEAD
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Internal
Incident Investigation Report
Doc No. 1 / IMS / F / 32 Revision No.0 Date: 01/07/2019
Annexure
Incident Body Part
Type of Incident Nature of injury Agency
Category Injured
Near Miss Caught in between Head Crush Machine & Tools
Working
Property Damage Explosion Face Fracture
Environment
Contusion / Means of
Fire Fall of Person Neck
Compression transportation
First Aid Fall of Material Shoulder Burn Lifting Tools/Tackles
Non-Reportable Fall / Flying of Object Hand Cut injury Equipment
Reportable (Non- Materials,
Struck on Object Finger Abrasion
Fatal) Substances
Reportable (Fatal) Struck by Object Palm Sprain / Swelling Hand Tools
Trunk (Neck to
Over exertion Amputation Protruded Objects
waist)
Wrong movement Leg Fatality Trenches / Pits
Exposure to extreme Others (Please Others (Please
Hip
temperature specify) specify)
Animal Bite Back / Dorsal
Others (Please
Electrocution
specify)
Electric Shock
Road Incident
Others (Please specify)
Prepared & Issued DIVISION
OHS HEAD Authorized By
By HEAD
Page | 5 of 6
Internal
Incident Investigation Report
Doc No. 1 / IMS / F / 32 Revision No.0 Date: 01/07/2019
Prepared & Issued DIVISION
OHS HEAD Authorized By
By HEAD
Page | 6 of 6
