Incident Report Incident No. 11081
Preliminary Report
Outline of Incident Employee No.
 
 
Date of Incident
 Incident Details Location
Time of Incident
 Injury
STOP 6 INCIDENT
  Body Part
Category of STOP 6
Type of Incident
Injured Person Status
To be completed if a non Webroy Employee
Age Gender Job Title   Length of Experience Years Months
  Length of Service Years Months
Sample Obtained for Substance ?
  Breathalyser Test Conducted ?
Result of Substance Sample Result of Breathalyser Test Test 1          Test 2
 
Preliminary Report Compiled By: Signature:   Date:
Verified By: Signature:   Date:
Final Report
Photo / Sketch Description of Incident / Sequence of Events
Suspected Causes
Countermeasure Responsible Person Target Date Completion Status
 
Final Report Complied By: Signature:   Date:
 
To be verified by HR Administrator
Form Annexure 1 Completed ?
  Incident Reported to DOL?
  Form WCI 2 Submitted
               
Remarks by Health & Safety Commitee
Date reviewed by Health & Safety Committee :
 
Verified By Management
SHE Officer  Maintenance Manager Production Manager CEO