Accident Notification Report

DATE: 3/12/2015
ACCIDENT NOTIFICATION FORM

SIHCI / CICO
ACCIDENT NOTIFICATION REPORT
Notification N ;
1
Please fill in this form and immediately send it to the Administration Manager in case an accident occurs; with a copy to
Managing Director and Plant Manager.
Vehicle Make & ModelToyota hiluxDouble cabin. Reg. No. UAU 692 X
Company No.
Date: 13
/ 02/ 2016
Hour: 09
/ 50
pm
Place:.....BANA BANA BARRACKS..........................KM ......................................................................................

.................
Description
4
5
of
the
accident:
The driver of motor vehicle was trying to dodge a cow when he lost control of the vehicle and it overturned injuring
two people and killing one
Drivers Name: LI/MA
License / Permit No10462038/2/1
Employees ID NoNIL..
Date of Employment: ....

Injured Person(s)
Name(s) YUEN M/A. Description of the injured Person (s)
(CICO Workers / Third Party) LI M/A..
..
...
...
...
(If they are many, you can use extra sheet and you attach it to this form)
Witness(s)
a) Name:..Tel No
Remarks:
b) Name:...Tel No...
Remarks:.
c) Name: ...Tel No...

Remarks..
Police Report Attached
Drivers Statement Attached
Witnesss Report Attached
Drivers Permit Copy Attached
PROJECTMANAGERS NAME: .
DATE:..
SIGNATURE:
SIHCI /CICO
Date / Year:
INCIDENT REGISTER
Item
Date
Notification
Report
Revision
Description
Date
FTL
Legenda
Item
Project Code - Progressive Accident Number
Notification
Accident Notification Date
Report
Report date of issue
Revision Date
Revised report as per DQS/DP comments date of issue (if the case)
Classification
A, B or C
Type of Accident
FTL
Fatal Accident LTI

Lost Time Injury
CI
Commuting Injury
RTA
Road Traffic Accident
NM
Near Miss
DP
Damages to Properties
EI
Damages to Environment
Section of Work
Section of accident
Type of Accident
Classification
24. ANNEX B; ACCIDENT NOTIFICATION FORM

Occupational Health & Safety Management Plan
Page 54 of 58
LTI
RTA
CI
DP
Work
EI
NM
Section
Cause
Status O/C
(Open
Closed)
25. ANNEX C: INJURY MEDICAL REPORT
SIHCI/ CICO
MEDICAL INJURY REPORT
Please fill in this form and immediately send it to the Administration Manager in case an accident occurs; with a copy to
Managing Director and Plant Manager.
Details of the
Event :
Time: _
2
Date: /
3
Injury Location:
Details of the injured

person :
Designation:
Name:_
Department:_
ID No.:
Date of birth:_
4
Date of employment:
Nationality:
/
a) What Happened
/ Description
Gender:
of Male
the
injury:
Female
Age
b) Causes
Contact with
Plants
Hit against
Vehicles
Hit by
Tools
Fall at the same level
Materials / Substances
Pricked by
People / Animals
Crushed by
Machine parts
Fall from a height (>2mts)
Tanks and containers
Struck him/her self with
Handling
Lifting
Equipments
Fall from the same level
Others (Specify)
Burns / Fire
Run over
False movement
Vehicle / Equipment Accidents
Others (describe)
5
Abrasion, Scratch
Injury
Classification:
Hernia
Compression
Crushing
Amputation
Dislocation
Cuts /Laceration
Asphyxiation
Electrocution
Radiation
Animal / Insect bite
Inflammation
Post-traumatic stress
Burns
Infection
Dehydration
Bruising
Foreign body
Freezing
Page 55 of 58
Contusion
Concussion
Fracture
Multiple
Sprain
Other
(Specify)
Effects of Toxic Substances
Strain
Part of the body

injured:
LR
Ear
6
Head
Eye
LR
Face
Neck
Chest
Abdomen
Elbow L R
Wrist
LR
Hand
LR
Thigh L R
Knee
LR
Leg
LR
Foot
Spine
Shoulder
R
Arm
LR
Pelvis
Hip
LR
Fingers L R
3 4 5
LR
Toes 1 2
Other Observations by the medical personnel:
The Patient was treated

from:
st
nd
1 Clinic / Hospital
2 Clinic / Hospital
Name of medical facility
rd
Clinic / Hospital
Name ofthe
medical
facility
Describe
kind
of treatment given: Name of medical facility
Prognosis:
10
Fist Prognosis.
From;
To;
No. Days:
11
Multiple injuries
1 2 3 4 5
LR
Final prognosis
/_
/
/_
/
From;
/_
To;
Permanen t disability
/
Death
Yes No
No. Days:
If any Instructions relating to work, please describe:
26. ANNEX D: SAFETY HAZARD REPORT

SAFETY HAZARD REPORT
To:
From: Safety Department
Location:
Hazard Spotted:
Date:
Time:
Description of Situation:
Suggested measures:
Action before:
Safety Inspector:
Signature
Eventual comments from receiver:
Receiver for knowledge and receipt:
Signature
Measures Taken:
Closed date:
Safety Officer
Safety Officer:
Signature
Project Manager
ACCIDENT INVESTIGATION REPORT

SIHCI /CICO
UGANDA
DATE: / /
INCIDENT INVESTIGATION REPORT
PROJECT SITE;
1
Please fill in this form and immediately send it to the Administration Manager in case an accident occurs; with a copy to Man aging
Director and Plant Manager.
General Information about the incident.

- Location:
- Drivers Name:
Date:
Time
License / Permit No
- Date of Employment:
Employees ID No
Alcohol test Results
Description of the incident:
In the course of incident the following were damaged / injured:

People
Company Property
Environment
Others
Positive
Negative
None
Specify the Class of incident in relation to severity of damage or injury:

5
7
8
Class A (Slight)
List of People involved:

1. Name:
2. Name:
3. Name:
Class B (moderate)
Class C ( very Serious)

Employee No.
Employee No.
Employee No.
Task:
Task:
Task:
List of property (equipments , vehicles, plants etc) involved:

1.
2.
3.
Causes of the event:
Witness(s)
1. Name:
2. Name:
3. Name:
Corrective measures taken:
10
Other information if any:
11
Enclosures:
Police Report Attached
Drivers Statement Attached
Witnesss Report Attached
Drivers Permit Copy Attached
Employee No.
Employee No.
Employee No.
Task:
Task:_
Task:
12
Project Managers Name:
Signature:
Date:

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DATE: 3/12/2015

ACCIDENT NOTIFICATION FORM

ACCIDENT NOTIFICATION REPORT

Place:.....BANA BANA BARRACKS..........................KM ......................................................................................

License / Permit No10462038/2/1

Date of Employment: ....

c) Name: ...Tel No...

Project Code - Progressive Accident Number

Accident Notification Date

Report date of issue

Fatal Accident LTI

Road Traffic Accident

24. ANNEX B; ACCIDENT NOTIFICATION FORM

25. ANNEX C: INJURY MEDICAL REPORT

Details of the injured

Fall at the same level

Fall from a height (>2mts)

Tanks and containers

Struck him/her self with

Animal / Insect bite

Part of the body

Other Observations by the medical personnel:

The Patient was treated

Name of medical facility

If any Instructions relating to work, please describe:

26. ANNEX D: SAFETY HAZARD REPORT

From: Safety Department

Eventual comments from receiver:

Receiver for knowledge and receipt:

ACCIDENT INVESTIGATION REPORT

General Information about the incident.

Alcohol test Results

Description of the incident:

In the course of incident the following were damaged / injured:

Specify the Class of incident in relation to severity of damage or injury:

List of People involved:

Class C ( very Serious)

List of property (equipments , vehicles, plants etc) involved:

Corrective measures taken:

Other information if any:

Project Managers Name:

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