| DATE & TIME OF INCIDENT |
Date Incident:
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Fill in the date of incident
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Time Incident:
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Fill in the time of the incident
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Location Incident:
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Fill in the location of the incident
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Business Unit:
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CHOOSE BUSINESS UNIT
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Department:
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CHOOSE DEPARTMENT
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# Of people directly involved (UNINJURED or INJURED):
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Fill in the # of people who are injured or uninjured
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# Of people indirectly involved (UNINJURED or INJURED):
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Fill in the # of people who are involved but uninjured
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Total # of people involved:
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Fill in the total # of people who are involved in this incident
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Involved Person(s) |
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Name
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Fill in the names of the people who are involved
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Involvement
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Fill in their involvement (e.g.: driver, witness, maintenance)
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Company
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Fill in the company name
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Department
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Fill in the company department
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Signature
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Each person involved should sign here in this section
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Delete
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Classify Incident:
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Select Incident Classification
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Short Description of Incident:
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Choose an incident classification (Human, Equipment, Property, Environment) then write a short description
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Type Incident:
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Select Type of Incident
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Category Incident:
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Choose Category of Incident
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Incident Short Description:
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Choose Incident Short Description
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Other:
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Fill in a short description of the incident using the incident types & incident short description
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DETAIL DESCRIPTION OF INCIDENT:
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Write a clear description of the incident by asking critical questions such as:
- What happened according to you?
- What did you see?
- Who was there?
- What caused it?
- How many hours did you sleep in the last 24 hours?
- Are you on medication?
- Are you under the influence of drugs & alcohol?
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Root Cause:
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Write the root cause of the incident by using the 5why-method
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Contributing Factors:
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Write the contributing factors of this incident
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Direct Actions:
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Write the direct actions taken by supervisor
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Suggestions To Improvement:
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Write at least one suggestion to improve the safety management system
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Report incident to other B.U. & Departments:
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Choose Report to other Business Unit & Departments or not
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Date of Reporting:
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Fill in the date of reporting the incident
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Time of Reporting:
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Fill in the time of reporting the incident
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Reported By:
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Fill in the name of the person who reported the incident
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PHOTOS:
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Add all relevant photos of the incident
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