ACCIDENT REPORT

Project: _______________

Date of the Accident: Time:

Place:

DESCRIPTION OF WHAT HAPPENED/WAS OBSERVED:

What could be happen: YES NO

Injury

Material Damage

Were persons involved

Plants/Equipments Involved:

Probable Causes:

Action to Prevent

Reported by Report Compiled by Checked & Approved byName: Name: Name:

Job Title: Job Title: Job Title:

Signature: Signature: Signature:

Date: Date: Date:

Sr. No: ______