Incident Report Form
PROJECT:
Preliminary
NOTIFICATION
PART 1 (Initial notification of significant incidents must be reported to the Project Manager and HSE
Manager within 1 hour. This initial Part 1 report must be submitted by the contractor to HAMAT
within 24 hours of the incident occurrence)
Contractor’s Name
Incident Date: 00/00/2024 Incident Time: 00.00 AM
Incident Location: Repeated incident? Yes No
Involved Parties Choose an item.
Near Miss
Injury and illness
Environmental Effects
Incident Type
Property Damage (Fire / Diesel generator)
Social / cultural heritage
Community / government / media / reputation
Cost of Damage if any Choose an item.
Incident Consequence Severity (Low – Medium – High)
Description of incident: (Who, what, how, when)
Who:
When:
What:
How:
Details of Injury/Damage/Impact: (Nature and extent of injuries/damage/impact)
Immediate actions taken following incident:
Final Report Expected Issuing Date: Click or tap to enter a date.
Signatures
Name Position Date Signature
“HSE Personnel”
“Construction manager”
NO BLAME CULTURE IS OUR PRINCIPAL
This document and its contents are confidential and should not be distributed outside HAMAT
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Incident Report Form
Required documents:
• PTW
• Worker Identification
• Risk Assessment
• Statements of: (worker, Supervisor, and witnesses)
• Photos of the damage\injury
NO BLAME CULTURE IS OUR PRINCIPAL
This document and its contents are confidential and should not be distributed outside HAMAT
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