SmartCheck | COMPUTERISED MAINTENANCE MANAGEMENT SYSTEM

Report Incident

Document No^*

Select Department

Select Asset^(Optional)

Select Sub Asset^(Optional)

Incident No

Incident Visibility

Incident Type

Weather condition

Location of incident^*

Incident reporting source^*

Date of incident

Time of incident

12 hours format

PERSONAL SAFETY

Risk Identified

Near Miss

Minor/No Lost WorkdayCase

Major/Lost WorkdayCasl

Fatality

Struck by

Trip

Fall

Over Exertion

Slip

Stuck in Lift

Exposed

Occupational illness

Others(specify)^*

PERSON AFFECTED

On roll

Contractual

Vendor of

Visitors

Others(specify)

Details of the injured person

Name

Company

Department

Nature of injury

Treatment

Select the body part injured

Medical emergency

Note: Number of days away from work due to incident (applicable only for Lost work day case - on roll & contractual - onsite staffs only):

Details of the injured person

Name

Company

Department

Details of the type of emergency

Equipment failure

Description of the equipment

Location

Service effected

Service failure

Details of the location affected

Environmental

Property Damage

Security

Fire

Impact

Incident Attribution

Brief of the incident^*

Affected person's statement^*

Witness - 1 statement^*

Witness - 2^*

	People Involved in RCA
	SNO	Name	Department	Company	Contact No	Remarks

Why? 1^*

Why? 2^*

Why? 3^*

Why? 4^*

Why? 5^*

	Corrective action
	SNO	Name

Corrective action

Immediate corrective action

Permanent corrective action

Preventive action^*

Learnings from the incident^*

Recommendations of reviewer^*

Attachment1

Attachment2

Attachment3

Attachment4

Attachment5

Incident Report Prepared by

Name:

Date:^*

Designation:

Incident Report Reviewed by

Name:

Date:^*

Designation:

Report Incident

Document No^*

Select Department

Select Asset^(Optional)

Select Sub Asset^(Optional)

Incident No

Incident Visibility

Incident Type

Weather condition

Location of incident^*

Incident reporting source^*

Date of incident

Time of incident

12 hours format

PERSONAL SAFETY

Risk Identified

Near Miss

Minor/No Lost Workday Case

Major/Lost Workday Casl

Fatality

Struck by

Trip

Fall

Over Exertion

Slip

Stuck in Lift

Exposed

Occupational illness

Others(specify)^*

PERSON AFFECTED

On roll

Contractual

Vendor of

Visitors

Others(specify)

Details of the injured person

Name

Company

Department

Nature of injury

Treatment

Select the body part injured

Medical emergency

Note: Number of days away from work due to incident (applicable only for Lost work day case - on roll & contractual - onsite staffs only):

Details of the injured person

Name

Company

Department

Details of the type of emergency

Equipment failure

Description of the equipment

Location

Service effected

Service failure

Environmental

Details of the location affected

Property Damage

Security

Fire

Impact

Incident Attribution

Brief of the incident^*

Affected person's statement^*

Witness - 1 statement^*

Witness - 2 ^*

	People Involved in RCA
	SNO	Name	Department	Company	Contact No	Remarks

Why? 1^*

Why? 2^*

Why? 3^*

Why? 4^*

Why? 5^*

	Corrective action
	SNO	Name

Corrective action

Immediate corrective action

Permanent corrective action

Preventive action

Learnings from the incident

Recommendations of reviewer

Attachment1

Attachment2

Attachment3

Attachment4

Attachment5

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Incident Report Prepared by

Name:

Date:^*

Designation:

Incident Report Reviewed by

Name:

Date:^*

Designation:

	Company Name

	Name
	Email Id
	User ID / Mobile Number
	Address

	Location
	Pin Code

Notice

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