Incident Report
Incident Report
Incident Report
NIOSH
Page No : 1 Of 4
INCIDENT REPORT
Revision No : 00
Case No :
Dislocation Head
Exposure Upper Limb
Foreign Body Lover Limb
Fracture Treatment Obtained
Heart / Circulatory condition First Aid Treatment
Infection disease Panel Clinic
Inhalation Hospital Casualties
Internal injury Hospi
a
l
Ad Nerve System Injury Other:
mit
ted
Poisoning
Out come of Injured Person
Puncture
Respiratory No of work day lost?
Skin Disorder Eye Organ
Sprain or Strain Ear Teeth Not yet returned to work
Other Nose Brain (Inform Safety & Health
Form No :
NIOSH
Page No : 2 Of 4
INCIDENT REPORT
Revision No : 00
Case No :
Officer)
(What, When, Where, Why, How?) (Explain in full including dates, location, cause and action)
GENERAL FAILURE
(Hardware Design of Engineering, Maintenance Management, Procedure, House Keeping, Communication, Training)
Human / Job Factor Machinery / Material Factor
NIOSH
Page No : 3 Of 4
INCIDENT REPORT
Revision No : 00
Case No :
Signature
ggf
Details of Verification
Verified by
Verified date
(Safety & Health Officer)
Signature
ggf
Details of Effectiveness
Evidence of Effectiveness:-
Effectiveness ………………………………………………………………………...
………………………………………………………………………...
Status Closed Status Open
………………………………………………………………………...
………………………………………………………………...………
Verified by
Verified Date
(Safety & Health Officer)
Signature
SPACE FOR ADDITIONAL INFORMATION, SKETCHES, PHOTO, LOCATION MAP & ETC
Form No :
NIOSH
Page No : 4 Of 4
INCIDENT REPORT
Revision No : 00
Case No :
ACKNOWLEDGED BY
HOD responsible
ESH Manager
Operations Manager
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