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Incident Investigation Report

GENERAL INFORMATION				Rig:
				Report No.:
Date of Accident:		Time of Accident :		Place of Acc.:
Category of Accident : {{DYNAMIC_CHECKBOXES_1_2_C3}}
Short Description of Incident :

DETAILS OF INJURED PERSON  -
Surname :		Initials :		Sex: {{DYNAMIC_CHECKBOXES_2_4_H}}	Date of Birth :
Occupation :		Job at Incident :		With SGD: yrs In Present Job: yrs Total Industry Experience : yrs
Type of Person : {{DYNAMIC_CHECKBOXES_2_11_H}}
SGD Pers. No.:		Name :		Name :
Department :		Employer :		Employer :

Time into Duty :		Work Schedule :
Shift : Hours	Trip: days	Report Date :	Report Time :	Leaving Date :	Leaving Time :

First Treatment By (Position):

Name :

Date :

{{DYNAMIC_CHECKBOXES_6_2_C3}}

Nature of Injury : {{DYNAMIC_CHECKBOXES_6_1_C3}}

SUPERVISORS INITIAL ASSESSMENT OF INCIDENT AND ACTION
Estimate Cost (√) : {{DYNAMIC_CHECKBOXES_7_1_V}} Remarks:	Injury Class (√) : {{DYNAMIC_CHECKBOXES_7_5_V}}
a)    Potential Severity Rating :
b)    Incident Actual Severity :

Level of Investigation : {{DYNAMIC_CHECKBOXES_8_1_H}}

Immediate Action Taken: (Reference from FIR)
Supervisor's Immediate Action to contain Incident and prevent Recurrence :
Job Category	Name	Status	Date

Identification of Root Cause (5 Why-Why Analysis)
Why's	Cause

Investigation Level   {{DYNAMIC_CHECKBOXES_11_1_H}}

Investigation Initiated – To be investigated by (Name):	Job Title :
Client Informed: {{DYNAMIC_CHECKBOXES_13_1_H}}       Client Staff to partake:
Endorsed by (Name):                                Pos. :                                Date :

FULL DESCRIPTION OF INCIDENT   ( Attach photograph/sketch of incident )

WITNESSES
Name	Address	Employer

Other Witnesses (if any) :

Attach Witnessed Form (if applicable) :

CONTROL OF WORK
Did the Job Require a Permit : {{DYNAMIC_CHECKBOXES_17_1_H}}	Was a Permit Raised : {{DYNAMIC_CHECKBOXES_17_2_H}}
Were the Permit Conditions Correct for the Job? :	{{DYNAMIC_CHECKBOXES_17_3_H}}
Were the Permit Conditions Complied With ? :	{{DYNAMIC_CHECKBOXES_17_4_H}}
Comment on any Irregularities Associated with the Permit :

RESULTS OF INVESTIGATION :

FINDINGS

IMMEDIATE CAUSES

Investigator Name (printed) :                                          Sign :                                          Date :

RECOMMENDED CORRECTIVE ACTIONS :
Description of Action Recommended :	Action Party:	Target Date:	Action Initiated by ATR No.:

INVESTIGATION APPROVAL (SITE MANAGEMENT)
COMMENTS (Rig Manager) :
Date :	Job Title :	Name :	Sign :
COMMENTS (Tool Pusher) :
Date :	Job Title :	Name :	Sign :

INVESTIGATION APPROVAL BY HO HSE DEPT.
Approval of Recommended Corr. Action : {{DYNAMIC_CHECKBOXES_21_1_H}}
Is Change required in Procedures : {{DYNAMIC_CHECKBOXES_21_2_H}} Doc. No. :
COMMENTS :
Date :	Job Title :	Name :	Sign :

SENIOR MANAGEMENT REVIEW / ENDORSEMENT
COMMENTS (CEO):
Date :	Job Title :	Name :	Sign :