Incident || Safety Cloud

Name of the Project:

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Name/ Age/ Sex and Designation of the injured (or) Name/ identity of the P and M Equipment:

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Name of the Contractor/Dept:

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Date and Time of the Incident:

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Location of the incident:

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Brief Description of the Incident:

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Nature of injury (if applicable):

Unsafe Acts/ Conditions which caused the accident:

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Safety application used (if applicable):

Remedial measures taken to prevent reoccurrence:

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Any other relevant information:

Status

Assigned to:

Witness 1:

Witness 2:

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Nature of damage/Injury:

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Location of injury:

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Type of injury:

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Unsafe Act:

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Unsafe condition:

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Witness 1 attachment (photo of written copy):

Witness 2 Attachment (photo of written copy):

Related Observations:

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Cause of Accident/incident:

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Correction action taken/suggested for:

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Prevention Action taken/Recommended:

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Name	Designation	Signature	Date

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