ACCIDENT / INCIDENT REPORT
Reference No.
*
ACCIDENT INFORMATION
Title
*
Date
*
Time
*
Weather Condition
JKR Office Responsible for the Accident
*
Section
*
Please Select
Location of the Accident e.g., JKR Premises, Construction Site, Ferry, etc.
CH e.g., CH 123+456.789
+
.
Project Name
*
Contract No.
Please Select
Project Cost
Please Select
Below than RM20 mil
More than RM20 mil
Accident / Incident Category
*
Please Select
Fatality
Serious Bodily Injury
First Aid / Minor Injury
Incident (Property Damage)
Dangerous Occurrence
Near Miss
Others
Please specify if Others
VICTIM PERSONAL DETAILS
Name
Job Title
Employer's Name
Age
Nationality
add
WITNESS PERSONAL DETAILS
Name
Job Title
Employer's Name
Age
Nationality
add
ACCIDENT DETAILS
Casualty Description (Chronology)
HSET Team Action & Response
Cause of Accident (factors leading to the event, unsafe act, unsafe condition, etc.)
Type of Vehicle
Property Damage
Number of Fatality
*
File
*Accept multiple files with 60 MB limit
Photos
*Accept multiple files with 60 MB limit
Reported By
Name
*
Position
Date
*
Submit