Accident Record Sheet ( Particulars of Industrial Injury)

1. Surname.....................................................................................................................................
2. Other Name................................................................................................................................
3. Address.......................................................................................................................................
4. Social Security No./ID No............................................................................................................
5. Male/ Female..............................................................................................................................
6. Normal Occupation......................................................................................................................
7. Date of Accident..........................................................................................................................
8. Time of Accident .........................................................................................................................
9. Date Accident Reported ( where later than 7 above)
.....................................................................................................................................................
10. Place of accident ........................................................................................................................
11. Kind of work being performed at the time of the accident
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12. Cause and particulars of the Accident:
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13. Particulars of Injury
.....................................................................................................................................................
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14. Witness of Accident
A. Name ..................................... B. Name..................................................

C Name....................................... D. Name..................................................

15. Rate of Remuneration: Rs......................... Per..........................................................

16. Whether period of incapacity days is less than two weeks : YES No
17. Specify number of days if less than two weeks:..........................................................................
18. Remuneration paid or due ( Not exceeding two weeks) Rs.......................................................
.......................................................... ........................................................
Signature of Employer Date
From : Health & Safety Officer

To General Manager Date : ...../...../.....

Accident Investigation Report

Name:........................................................ Post...............................................................

Department................................................ Section..........................................................

1. Case History

Date Of Accident ..............................................& Interview of the employee.........................................

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2. Investigation
A. Did the accident arise out of employee’s negligence ? state how?

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B. Did the accident arise out of the employer’s negligence ?state how?

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3. Recommendation to Employee:
...................................................................................................................................................
................................................................................................................................................
Signature of employee................................
4. Recommendation to Management :
A. ............................................................................................................................................
............................................................................................................................................
B. The above matter is of a repetitive/serious nature and was discussed with the HOD
concerned .......................................... on ...../...../.... ( fill in / Delete as appropriate ).........
..............................................................................................................................................
Health and Safety Officer ......................................................