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City Group
ACCIDENT / INCIDENT REPORT		Doc:Ref:No-HSE-F-33
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Rivision 01
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Date 28/12/2024
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Page 01 of 01
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Project Name:
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Client Details: Contract No:
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TYPE OF ACCIDENT : (Check all applicable squares)
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[ ]Injury[ ]Property Damage[ ]Vehicle[ ]Environmental Release
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NATURE:
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[ ]Severity[ ]Major[ ]Minor[ ]Very Minor
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DESCRIPTION OF ACCIDENT :
( Describe in detail: Indicate date & time of accident, prevailing conditions, use additional sheet (s) for witness statements, photographs and sketches or additional information to be followed by police report, if required)
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Date:Time:
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PROPERTY DAMAGES :
( Describe property and / or model, make, state year of vehicle etc)
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Description of damages and estimated loss :
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Owner :
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Address :
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INJURED PERSONS :
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1.Name: ……………………………………………….. ID: ………………………………………….. 3.Name:……………... ……………………………… ID: ………………………………………………………….
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2.Name: ……………………………………………….. ID: ……………………………………….... 4.Name: ……………………………………………… ID: …………………………………………………………
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WITNESS :
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1.Name: ……………………………………………………… Addresss: ………………………………………………… Tel: ……………………………………………………………………………
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CORRECTIVE ACTION TAKEN :
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Submitted by :……………………………… (Safety Officer ) Date : ………………………….
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Position : ……………………………
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PLANT IN CHARGE / HOD Comments:DATE :
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PREVENTIVE ACTION TO BE FILLED BY SAFETY OFFICER
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[ ]. Training [ ]. Awareness [ ]. Default Notice [ ]. Others
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HSE Dept Comments:DATE:
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GM Comments:DATE:
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Very Minor:- Little consequence
Minor:- First Aid Incident. Routine Maintenance, Repair
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Major: LTI or Illness. Damage or Environmental Impact
Severity:- Major Injury or Illness. Major Damage or Environmental Impact. Death or Total System Loss
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