ACCIDENT / INCIDENT REPORT
ACCIDENT / INCIDENT REPORT
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Location/Area/KM
Reference No.
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Date of Report
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Date of Accident
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Time of Accident
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Category of Accident/Incident
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Fatality
Bodily Injury
Damage to property
Occupational disease
Occupational poisoning
Near miss
Theft
Environmental mishap
Risk Category
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Fatality
Major
Minor
Near miss
Fatality
= immediate death or within a year of the accident
Major Injury
=> 4 calendar days hospitalization
Minor Injury
=< 4 calendar days hospitalization
Major Damage/Loss
=> RM20K
Minor Damage/Loss
=< RM20K
Task and Activity at the time of accident/incident
WITNESS PERSONAL DETAILS
VICTIM PERSONAL DETAILS
Severity of incident/impact to environment & medical treatment undertaken
Casual factors, events and conditions that contributed to the accident
Proposed corrective/preventive action/mitigation plan
Attachment (Incident/Accident Investigation Report)
*Accept multiple files with 60 MB limit
Photos
*Accept multiple files with 60 MB limit
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