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    Accident Report Form

    Uploaded by

    glenn umali
    This document contains an accident report form for recording workplace injuries. The form collects personal details of the injured employee, date and location of the accident, equipment involved, witnesses, and mechanism and nature of injury. Sections are included to note lost time, damage, recommendations, and signatures of reviewing supervisors. Guidelines state that the shift supervisor must investigate the incident, fill out the form, and forward it for review and validation up the management chain to the EHS personnel for filing.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Accident Report Form

    Uploaded by

    glenn umali
    106 views2 pages
    This document contains an accident report form for recording workplace injuries. The form collects personal details of the injured employee, date and location of the accident, equipment involved, witnesses, and mechanism and nature of injury. Sections are included to note lost time, damage, recommendations, and signatures of reviewing supervisors. Guidelines state that the shift supervisor must investigate the incident, fill out the form, and forward it for review and validation up the management chain to the EHS personnel for filing.

    Original Description:

    Accident

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    This document contains an accident report form for recording workplace injuries. The form collects personal details of the injured employee, date and location of the accident, equipment involved, witnesses, and mechanism and nature of injury. Sections are included to note lost time, damage, recommendations, and signatures of reviewing supervisors. Guidelines state that the shift supervisor must investigate the incident, fill out the form, and forward it for review and validation up the management chain to the EHS personnel for filing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    106 views2 pages

    Accident Report Form

    Uploaded by

    glenn umali
    This document contains an accident report form for recording workplace injuries. The form collects personal details of the injured employee, date and location of the accident, equipment involved, witnesses, and mechanism and nature of injury. Sections are included to note lost time, damage, recommendations, and signatures of reviewing supervisors. Guidelines state that the shift supervisor must investigate the incident, fill out the form, and forward it for review and validation up the management chain to the EHS personnel for filing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Purok Lansong, Brgy.

    Tambler General Santos, 9500


    Health and Safety
    ACCIDENT REPORT
    Date:
    I. Personal Details*
    Name: Occupation:
    Gender: Area:
    Age: Department:
    II. Details of the Accident*
    Date of Equipment
    Accident: Involved:
    Time: Reported to:
    Location: Witness/es:
    Full Details: (attach pictures if available)

    III. Mechanism of Injury** (if applicable)


    Caught in between Electric Shock Entanglement
    Struck by Slipping Crush/Collision
    Fall from elevation Run Over Others, specify _________________________

    IV.Nature of Injury** (If applicable)


    Amputation Dislocation Laceration/Open Wound
    Burn Fracture Sprain/Strain
    Concussion Foreign Object Superficial Injury
    Contusion/Crush Internal Injury Others, specify _________________________
    V.Location of Injury** (if applicable)
    Arm/Shoulder Hand/Fingers Hip/Legs
    Back Hip/Legs Foot/toes
    Eye Head/Face/Neck Internal organ
    Others, specify _________________________________
    VI. Result of Accident**
    Lost time injury (Yes/No): Damage to equipment/building/facility (Y/N): ________________
    No. of hours: _________________ Extent of damage: ____________________________
    Recommendation/Corrective Action**

    Conducted by: Reviewed by: Noted by:

    Supervisor Section Manager Department Manager


    Received by:

    EHS Personnel

    *To be filled up by Supervisor/Lead person ** To be filled up by Company Nurse


    Guidelines for Accident Report:

    1) With in the shift after the incident happened shift supervisor must conduct its
    investigation and analysis of the said incident in parallel with separate investigation of
    EHS personnel.

    2) Shift Supervisor must create an Accident Report depends on the his/ her conduct
    investigation and analysis.

    3) After making the Accident Report, shift supervior must forward the report to Section
    Manager to validate and review its corrective and preventive action made and after
    validation it will be noted by the Department manager.

    4) Accident report has been noted by the Department manager it will be received by EHS
    Section Personnel for validation of corrective and preventive action made.

    5) After validation of the Accident report EHS personnel will forward the report to
    Admin book keeper for records filing.

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