SmartCheck | COMPUTERISED MAINTENANCE MANAGEMENT SYSTEM

Raise Incident

Incident No :

Select Department^*

Select Asset^(Optional)

Select Sub Asset^(Optional)

Section 1: Incident Category

Type of Incident^*

Reported By :

Name^*

Job Title^*

Incident/Date & Time^*

Supervisor/Manager name: ^*

Have you told your supervisor/Manager about this injury/near miss?^*

Incident Information :

Building Name^*

Type Of Service^*

Incident Location (Where, exactly, did it happen?) ^*

Brief Incident Description ^*

Immediate response/ correction?

What parts of the body were injured? If a near miss, how could you have been hurt? ^*

Did the injured person visit the hospital/doctor for this Incident? ^*

Date & Time^*

Section 2: Investigation format (to be filled by investigation team leader)

	Person involved Information - Fill the details only if someone is injured
	SNO	Name of Injured Person:	Date of Birth	Gender	Employee ID	Employment type	Job Title	Work Shift

Describe the Incident (Step by step and attach photos if available )

Image1^(Optional)

Image2^(Optional)

Image3^(Optional)

Image4^(Optional)

Image5^(Optional)

Root Cause Analysis (RCA)

Cause Statement

Why 1

Why 2

Why 3

Why 4

Why 5

Root Cause Description resulting from the "5 Whys" analysis

Corrective/ Preventative Action


	SNO	Root Cause(s)	Corrective/ Prevention taken	Responsible person	Due Date (DD/MM/YY)	Completion date (DD/MM/YY)

Attachment1^(Optional)

Attachment2^(Optional)

Attachment3^(Optional)

Attachment4^(Optional)

Attachment5^(Optional)

Guidance

S.no.	Definitions
1	Injury and ill health : Adverse effect on the physical, mental or cognitive condition of a person These adverse effects include occupational disease, illness and death. The term injury and ill health implies the presence of injury or ill health, either on their own or in combination.
2	Incident: Occurrence arising out of, or in the course of, work that could or does result in injury and ill health. An incident where injury and ill health occurs is sometimes referred to as an accident. An incident where no injury and ill health occurs, but has the potential to do so, may be referred to as a near-miss, near-hit or close call. Although there can be one or more nonconformities related to an incident, an incident can also occur where there is no non conformity.
3	Corrective action: Action to eliminate the cause(s) of a nonconformity or an incident and to prevent recurrence.
4	First Aid Injury: First Aid Injury is an injury that requires a single first aid treatment and a follow-up visit for subsequent observation involving only minor injuries (Minor scratches, burns , cuts and so forth ) which do not ordinarily require medical care , and for which the person would typically immediately to their normal activities .
5	Loss Time Injury(LTI): A disabling occupational injury or illness that results in a person being unfit for work on any day beyond the day of the incident. Any day includes rest days, weekend days, leave days, public holidays or days after ceasing employment"
6	Man Days Lost : The day on which the injury occurred or the day the injured person returned to work are not to be included as man-days lost; but all intervening calendar days (including Sundays or, days off, or days of plant shut down) are to be included. It after resumption of work, the person injured is again disabled for any period arising out of the injury which caused his earlier disablement, the period of such subsequent disablement is also to be included in the man-days lost.
7	Environmental release: Any release (Oil or Chemical) which is a part of any routine or nonroutine operations and includes release from secondary containment such as spills or leaks into land or water. It also includes the discharge of effluent or air releases or soil contamination.
8	Reportable incident: All types of incidents falling under the category of Major and Critical as explained in the above table are reportable. Additionally, the accidents which are under legal obligations,such as Hazardous and Other Wastes (Management and Transboundary Movement) Rules, 2016 , need to be considered as critical reportable incidents.