INCIDENT REPORT
GENERAL INFORMATION
Incident Title    

Department / Project    

Subcontractor Incident    

Specific Location of Incident    

Incident Date & Time    

Reported By Name & Designation    

Incident Classification (Tick appropriate box)    

Fatality 

Permanent Total Disability 

Lost Work Day Case 

Medical Treatment Case 

First Aid Case 

Occupational Disease/Illness 

Dangerous Occurrence 

Traffic Related Injuries 

Environmental 

Near Misses 

Non-Work Related 

Property / Equipment 

Incident Risk Rating 

Severity
 Negligble(1)
Minor(2)
Moderate(3)
Major(4)
Catastrophic(5)
Likelihood
Rare(1)
Remote(2)
Occasional(3)
Frequent(4)
Almost Certain(5)
Risk Rating
Low risk(1-3)
Medium Risk(4-12)
High Risk(13-25)

Name of Witness (If any)    

Witness Contact    

Name of Witness (If any)    

Witness Contact    

DETAILS OF INCIDENT
Factual description of the incident (Who, What, Where, When, Why and How)    

Immediate action to prevent recurrence    

CONSEQUENCE
Injured Party (IP)    

IP Employer    

IP Identification Type & Nos    

IP Trade    

Injured / Illness Body Part    

Type of Injury / Illness    

Medical Leave

Start date    

End date    

Total Days    

Substance Discharged    

Amount Discharged    

Unit of Discharge    

Property Owner    

Damaged or Lost Equipment    

Estimated Value of Loss