EOHS MANANGEMENT SYSTEM

NEAR MISS / INCIDENT / ACCIDENT REPORT

NATURE OF THE
NEAR MISS INCIDENT ACCIDENT
INCIDENT
BRIEF DISCRIPTION
DATE &
PERMANENT
SEX: TIME OF
NAME OF THE PERSON DEPT. EMPLOYEE/
M( ) F( ) OCCURE
CONTRACTOR
NCE

ACTION DISPOSITION PROPOSED

CORRECTIVE ACTION
TAKEN ACTION PREVENTIVE ACTION
INCIDENT
ACCIDENT
DATE
OCCURANCE
OF
MANHOURS
DETAILS OF TREATMENT RESUM
LOST
LOCATION WITNESSED BY ING
BACK
FIRST AID
SENT TO HOME / HOSPITAL
IMPACT OR HAZARD
PART OF THE BODY
TYPE (TICK THE PROBABLE ROOT CAUSE
INJURED
APPLICABLE)
RESOURCE USE OF HANDS INSTEAD
HEAD
DEPLETION OF WORKAIDS
LAND
UNSAFE METHOD OF
CONTAMINATI EYE
MATERIAL HANDLING
ON
INEFFECTIVE SAFETY
AIR POLLUTION FACE
DEVICE
WATER UNSAFE STORAGE /
NECK
POLLUTION PILING
HEARING
SHOULDER BAD HOUSE KEEPING
IMPAIRMENT
FAILURE TO USE PPE’S
EYE INJURY ARM (GLOVES/GOGGLES/SHOE
S/BELT/ HELMET)
BRUISES / USE OF UNSAFE /
PALM
ABRASION DEFECTIVE TOOLS
ELECTRIC USE OF UNSAFE /
FINGER
SHOCK / BURN DEFECTIVE MACHINES
USE OF UNSAFE /
CUT CHEST
DEFECTIVE LADDER
FRACTURE / USE OF UNSAFE /
BACK
PUNCTURE DEFECTIVE PLATFORM
MAKING SAFETY DEVICE
HEAD INJURY ABDOMEN
INOPERATIVE
HEALTH THIGH / LEG
FAILURE OF PPE’S USED
COMPLAINTS / ANKLE
OTHERS FOOT / TOE SLIP / TRIP
AVOIDABLE. INCIDENT / UN AVOIDABLE
ACCIDENT INCIDENT / ACCIDENT
INCIDENT / ACCIDENT
COMMENTS
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