ACCIDENT / INCIDENT REPORT

No. _______

TO (PARA KAY)

: _______________________________________________________

FROM (MULA KAY)

: _______________________________________________________

DATE (PETSA)

: _______________________________________________________

WHAT (ANO)

: _______________________________________________________

WHO (SINO)
Person/s involved

: _______________________________________________________

WHERE (SAAN)
Place of Accident/Incident

: _______________________________________________________
_______________________________________________________

WHEN (KAILAN)

: _______________________________________________________

WHY (BAKIT)

: _______________________________________________________
_______________________________________________________

HOW (PAANO)
Details of Accident/Incident

: _______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

ACTION TAKEN
(NAGAWA)

: _______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

RECOMMENDATION
(MUNGKAHI)

: _______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

Prepared by:

Noted by:

(Name & Signature)

(Name & Signature of Supervisor)

To be submitted to any concerned unit/department:

Supervisor / HOD / Deputy GM / HR / Safety / Security

NEAR MISS REPORT

No. _______

NAME ORIGINATOR
(MULA KAY)

: _______________________________________________________

DEPARTMENT
(DEPARTAMENTO)

: _______________________________________________________

DATE (PETSA)

SUBJECT (PAKSA)
Anything with the potential to
cause an incident.

: _______________________________________________________
Housekeeping

Personal Protective Equipment (PPE)

Equipment /Material

Fire

Procedure (PTW, M/S. JSA)

Pressure / Energy

Environmental

Chemical

Health

Confined Space

Electrical

Rigging

Scaffolding

Heights

Others ________________________________________________
WHO (SINO)
Person/s involved

: _______________________________________________________

WHERE (SAAN)
Place or concerned location

: _______________________________________________________
_______________________________________________________

WHY (BAKIT)

: _______________________________________________________
_______________________________________________________

HOW (PAANO)
Details of Report

: _______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

ACTION TAKEN

: _______________________________________________________

(GINAWA)

_______________________________________________________

RECOMMENDATION
(MUNGKAHI)

: _______________________________________________________
_______________________________________________________
_______________________________________________________

Prepared by:

Noted by:

(Name & Signature)

(Name & Signature of Supervisor)

To be submitted to any concerned unit/department:

Supervisor / HOD / Deputy GM / HR / Safety / Security