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:		Date:
Supervisor’s Name:	Supervisor’s Signature:		Date:
Project Name:		Project Location:

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