QCS/50/00/SA/PC/NA/111
Attachment-2
PRELIMINARY REPORT OF INCIDENT
To: Project To: Safety Management Office
Report No. Date : Site Manager SHES Manager Prepared by
PERSONAL INJURY PROPERTY DAMAGE PROCESS LOSS NEAR MISS
Field Office
WORK RELATED LOCATION NON-WORK RELATED DEPARTMENT / SUBCONTRACTOR INVOLVED: (NB: ALL INCIDENTS ARE TO BE REPORTED WHETHER WORK RELATED OR NOT)
INJURED NAME AGE/SEX NATIONALITY OCCUPATION DATE TIME Apparent Nature and Extent of Work Injury/Illness, Property Damage Information Available at Present Causes Apparent at Present Immediate Actions Taken and/or To be Taken
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