FORM

Doc. Code:FM-ESH-03-03

Rev. No.:1

Effectivity Date:February 15, 2025

Page/s:1 of 6

TITLE:

INCIDENT / ACCIDENT REPORT FORM

Project Name / Location: Accident / Incident Report Number:

TYPE OF ACCIDENT / INCIDENT
Person/s Involved:	ID Number:	Accident / Incident Date:
		Accident / Incident Time:
		Specific Accident / Incident Location:
Near Miss Equipment Failure Company Policy non-compliance Body Injury Fire Hazard Property Damage Violence Others:
ACCIDENT / INCIDENT CLASSIFICATION
Medical Treatment First Aid Restricted LTA Fatality
Estimated cost of property damage:
What job or activity was being engaged in at the time of injury/property damage?
What type of Equipment Involved:
Described how the accident/incident occurred?
What were the consequences of the accident/incident?
What actions have been taken?
Recommendation to prevent re-occurrence of incident
Witness/es Reporting Person’s Name & Signature			Contact Number:
Employee’s Name:	Employee’s Signature: Click to upload signature image		Date:
Supervisor’s Name:	Supervisor’s Signature: Click to upload signature image		Date:
Project Name:		Project Location:

Note: Accident/Incident report shall be submitted within 24 hours to ESH department and HR department by Supervisor/Foreman.

FORM

Doc. Code:FM-ESH-03-03

Rev. No.:1

Effectivity Date:February 15, 2025

Page/s:2 of 6

TITLE:

INCIDENT / ACCIDENT REPORT FORM

PHOTO DOCUMENTATION

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FORM

Doc. Code:FM-ESH-03-03

Rev. No.:1

Effectivity Date:February 15, 2025

Page/s:3 of 6

TITLE:

INCIDENT / ACCIDENT REPORT FORM

PHOTO DOCUMENTATION

PHOTO 3

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PHOTO 4

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FORM

Doc. Code:FM-ESH-03-03

Rev. No.:1

Effectivity Date:February 15, 2025

Page/s:4 of 6

TITLE:

INCIDENT / ACCIDENT REPORT FORM

PHOTO DOCUMENTATION

PHOTO 5

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PHOTO 6

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FORM

Doc. Code:FM-ESH-03-03

Rev. No.:1

Effectivity Date:February 15, 2025

Page/s:5 of 6

TITLE:

INCIDENT / ACCIDENT REPORT FORM

PHOTO DOCUMENTATION

PHOTO 7

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PHOTO 8

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FORM

Doc. Code:FM-ESH-03-03

Rev. No.:1

Effectivity Date:February 15, 2025

Page/s:6 of 6

TITLE:

INCIDENT / ACCIDENT REPORT FORM

PHOTO DOCUMENTATION

PHOTO 9

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PHOTO 10

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