Safety Management System Ref:
Sheet:
Accident/Incident Reporting and Investigation Issue:
(Safety performance – Monthly Report) Date:
This form is to be completed and returned to the Group Safety Manager by the ___ of each month for the previous
month’s statistics.
Reporting period
Contract name/number
Submitted by
Designation
Date submitted
Section 1 Accident details (brief resume of accidents for the reporting period)
Type of accident Total for month Cumulative total Remarks
Fatality
Major Incident
Over 3 day
Dangerous occurrence
Reportable disease
Damage to property
First aid cases
Other incidents (damage,
negligence, drunkenness etc.
Environmental incidents
Average daily workforce
number
Total monthly man hours
Section 2 Disciplinary notices
Total for month Cumulative total Remarks
Main Contractor Personnel
Sub-contractor
Other (visitors etc)
Section 3 Safety Inductions
Total for month Cumulative total Remarks
Main Contractor Personnel
Sub-contractor
Other (visitors etc)
Section 4 Toolbox talks carried out
Total for month Cumulative total Remarks
Main Contractor Personnel
Sub-contractor
Other (visitors etc)