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Incident Reporting Form Template



LOGO
               HSE
                                     INCIDENT/nearmiss fORM                                     

Report Status:
Preliminary
Type:
Incident
Incident No:

General Information
Evaluation of Risk
Incident Date:

Loss Severity Potential:

Incident Time:

Company Name

Location of Incident:

Probable Recurrence Rate:

Section:

Employee Name/ID No

Occupation:

Service In The Job

Supervisor/Incharge:

Shift:

Witness:

Events Leading up to and Description of Incident (Include Description and Losses)
(What, When, Where, Why, Who, How)

Cause Analysis – Direct and Underlying
The Unsafe Practices, Condition Contributory Factors most directly causing the event.
Unsafe Practice/s:

Unsafe Condition/s:

Contributory Factor/s:

Direct Cause/s:

Root Cause/s:

Preventive And Corrective Actions
Corrective Actions:

Preventive Action:

Injury Information
Type of Injury:

Body Part Injured:

Cause of Injury:

Agency of accident (Energy Source):

First Day of Lay-Off

Date of Return To Work:

Number of Working Days Lost:

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