INCIDENT INVESTIGATION REPORT (IIR)
PART A (Type of Accident)
Major Accident (Reportable to MOM under both WSH Act & WIC Act) 

Minor Accident (Reportable to MOM under work Injury Compensation (WIC) Act only) 

Minor Accident (Non-Reportable to MOM) 

Staff Injury / Public Member Injury 

PART B (Detail of Accident)

Workplace No     

Place of accident     

Occurrence date and time    

First reported date and time     

Reported by     

PART C (Detail of Injured / Victim)

Name     

Date Joined Service     

Direct Employer     

Fin No     

Work Employer     

Nationality     

Date of Birth     

Marital Status     

Gender     

Designation / Occupation     

Race     

The injured sent to

First Aid 

Private Doctor 

Hospital 

Polyclinic 

Name of Clinic / Hospital     

PART D (Lost Time)
Estimated (if actual man-day lost is not available)
3 days or lesser 

More than 3 days (consecutive or otherwise) 

Hospitalized more than 24 hour 

Immediate return to work 

First aid given only 

Hospital referral 

State actual of man-days lost      

(excluding PH & Sunday)

Period of Medical Leave (Days)     

Period of Medical Leave from     

Period of Medical Leave to     

PART E (Details of Injury)
Nature of Injury ( Tick wherever applicable)
1. Chemical Burns 

2. Physical Shock 

3. Fracture 

4. Asphyxia/Drowning 

5. Puncture Wound 

6. Heat Stress and strain 

7. Chemical Burns 

8. Dermatitis/Skin Disease 

9. Noise Induced Deafness 

10. Shoulder to Groin/Hip 

11. Tooth Injury 

12. Permanent Disability  

13. Fatality 

14. Amputation 

15. Poisoning 

16. Effects of Electricity 

17. Bruises/Crushing/Contusions 

18. Effects of Radiation 

19. Faint/Giddy 

20. Heat Burns 

21. Sprain/Strain 

22. Freezing/Frostbite/Hypothermia 

23. Concussion/Internal Injury 

24. Other Injury (Specify) 

25. Laceration/Cut 

26. Dislocation 

27. Numbness  

28. Eye Injury 

Injury Body Part (Tick wherever applicable)
1. Head/Face/Neck 

2. Injury linked to entire body 

3. Eye 

4. Lower Limbs (Legs) 

5. Upper Limbs (Arms) 

6. Feet/Toes 

7. Hand/Fingers 

8. Not Applicable 

Exact Description (Tick wherever applicable)
Exact Description(Left) 

Exact Description(Right) 

PART F (Description of Accident)

PART F (Description of Accident)     

Type of Accident (Tick wherever applicable)

1. Caught In/Between Objects 

2. Exposure to Electric Current 

3. Suffocation/Drowning 

4. Cut/ Stabbed by Objects 

5. Striking Against Objects 

6. Fires & Explosion 

7. Struck by Moving Objects 

8. Exposure to Biological Materials 

9. Slips, Trips and Falls 

10. Falls from Heights 

11. Struck by Falling Objects 

12. Physical Assault 

13. Stepping on Objects 

14. Exposure to Extreme Temperature 

15. Over-Exertion and Strenuous Movements 

16. Other (Specify) 

PART G (Causes of Accident)

(1) Direct Causes

I) Unsafe Conditions (Tick whenever applicable)

1. Absence of safety means / Congestion/ Restricted action 

2. Inadequate warning system 

3. Dressing apparel hazard 

4. Inadequate ventilation 

5. Environmental hazard (gas/dust/smoke) 

6. Noise hazard 

7. High temperature hazard 

8. Presence of fire/ explosion hazard 

9. Hazardous arrangement / Inadequate guarding 

10. Poor housekeeping 

11. Inadequate illumination 

12. Radiation hazard 

13.Inadequate/ Improper PPE 

14. Unsound structure 

15. Improperly/ faulty equipment 

16. Others (key details refer to “Remarks”) 

Remarks      

ii) Unsafe practice (Tick wherever applicable)

1. Careless / reckless 

2. Taking improper/unsafe position or posture 

3. Disregard instructions 

4. Making safety devices not in operative mode 

5. Driving error 

6. Not attentive while working 

7. Failure to secure / warn 

8. Operating/working at unsafe speed 

9. Horseplay 

10. Operating/working without authority 

11. Under influence of alcohol/drugs 

12. Tampering with equipment in motion 

13. Improper/wrong use of body part 

14. Using improper/unsafe equipment 

15. Improper/unsafe lifting/carrying 

16. Using proper equipment unsafely 

17. Improper working methods & sequence 

18. Fail to use proper tools/ equipment 

19. Unsafe loading/mixing/placing 

20. Others (key details into “Remarks”) 

21. Intentional motive 

Remarks      

(2) Root Causes

I) Work Factors (Tick whenever applicable)

1. Lack of co-ordination/communication 

2. Inadequate/lack of work procedures 

3. Inadequate/lack of engineering 

4. Pressure from external influence 

5. Inadequate equipment being used 

6. Poor selection/placement  

7. Inadequate/lack of maintenance 

8. Wear and tear 

9. Inadequate/lack of supervision 

10. Others (key details into “Remarks”) 

Remarks      

ii) Human Factors (Tick whenever applicable)

1. Foul play  

2. Lack of skill 

3. Fatigue/stress 

4. Lack of training 

5. Inadequate capability 

6. Needs conflicting with safety 

7. Illness 

8. Not qualified 

9. Improper or lack of motivation/interest 

10. Unsafe attitude 

11. Improper assignment of personnel 

12. Non human factors 

13. Lack of knowledge 

14. Others (key details into “Remarks”) 

Remarks     

(3) Weakness of Safety management System

I) General (Tick whenever applicable)

1. Safety policy 

2. Evaluation, selection and control of SC 

3. Safe work practices 

4. Safety inspections 

5. Safety training 

6. Maintenance regime for all machinery 

7. Group meetings 

8. Risk Assessment and Management 

9. Incident investigation and analysis 

10. Emergency preparedness 

11. In-house safety rules and regulations 

12. Control of movement and use of hazardous substances  and materials 

13. Safety promotion 

14. Occupational health programs 

15. Not applicable 

16. Others (key details into “Remarks”) 

Remarks     

PART H (Corrective Action & Preventive Action)
PART-H(Corrective Action & Preventive Action)

PART I (Recommendation)
PART I (Recommendation)     

PART J (Detail of Investigation recorded by Project WSH Committe)

Name of Secretary     

Signature of Secretary     

Name of Member 1     

Signature of Member 1     

Name of Member 2     

Signature of Member 3    

Name of Member 3     

Signature of Member 2    

Designation ; WSHO
Company ; Straits Construction
Date     

submitter