Incident/Accident Report

Unit /
Date Location
Site

INFORMATION ON THE INCIDENT/ACCIDENT

1 Nature of The activity
2 Location of the activity
3 Date of the incident/accident
4 Time of the Incident/accident
5 Weather Conditions (if apply)
Name of the in charge person with
6
Designation
4 Brief Description of the Incident/Accident:

INFORMATION ON INJURED PERSON OR OWNER OF DAMAGED PROPERTY

Name Date of Birth/Age

Address
Phone
Work: Home :
Numbers

Describe Nature of
5
Injury/Damage of property

MEIL/SAFETY/F-05/Rev.02
 Unsafe Acts/Conditions which
6
caused

7 Safety appliances (Relevant) used

a)

b)
8 Corrective action taken
c)

a)

b)
9 Preventive measures
c)

10 Witness with signatures

1.

2.

Signature of the Safety Officer Signature Project Head

MEIL/SAFETY/F-05/Rev.02