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ACCIDENT REPORT

Doc. No : HSEHK FORM-040 Date : 1 Mei 2011 Rev : 0 Page : 1 of 1

A. GENERAL DESCRIPTION Name Occupation Emp.No. / I/C Company Description of Accidents / Incidents :

Date of Accident Time of Accident Witness Accident Report No. For Office Use:

B. DESCRIBE WHAT THE EMPLOYEE WAS DOING AND HOW THE ACCIDENT / INCIDENT HAPPENED

C. WHAT WAS THE CAUSE(S)?

D. WHAT WAS THE IMMEDIATE ACTION TAKEN?

E. WHAT IS THE RECOMMENDED ACTIONS TO PREVENT THE RECURRENCE?

F. APPROVAL REMARKS : SIGNATURE NAME DATE PREPARED BY APPROVED BY

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