📍 When to use this template
- Immediately after any accident (injury), incident (property damage), or near-miss occurs.
- Triggered by any event requiring first-aid, medical treatment, or resulting in property/equipment damage.
- Filled by the Site Safety Officer/Engineer, in coordination with the supervisor of the affected area/personnel.
Sections & fields
Preview of the template structure. Download Excel to fill on site.
1Header / Project Info7 fields
Project Name
_____________
Contract / Package No.
_____________
Date of Report
_____________
Time of Report
_____________
Prepared By (Safety Officer)
_____________
Reviewed By (Project Manager)
_____________
2Incident Details6 fields
Date of Incident
_____________
Time of Incident
_____________
Exact Location on Site (Gridline/Floor/Area)
_____________
Type of Incident (e.g., Fall from Height, Electric Shock, Struck by Object, Property Damage, Near Miss, First Aid Case, Medical Treatment Case, Lost Time Injury)
_____________
Weather Conditions
_____________
Shift (Day/Night)
_____________
3Details of Affected Person(s) / Property9 fields
Name of Injured Person(s)
_____________
Employee ID / Contractor Name
_____________
Designation / Trade
_____________
Years of Experience
_____________
Nature of Injury (e.g., Laceration, Fracture, Burn, Sprain)
_____________
Body Part Affected
_____________
Description of Property/Equipment Damaged
_____________
Estimated Cost of Damage (INR)
_____________
4Immediate Action Taken7 fields
First Aid Administered (Yes/No)
_____________
Details of First Aid Provided
_____________
Shifted to Hospital (Yes/No)
_____________
Hospital Name & Location
_____________
Time of Shifting to Hospital
_____________
Site Secured / Work Stopped (Yes/No)
_____________
Notified to (Client/PMC/HO)
_____________
5Incident Description & Witness Statements9 fields
Detailed Sequence of Events (What happened step-by-step)
_____________
Activity being performed during incident
_____________
Tools/Equipment being used
_____________
Witness Name & Contact 1
_____________
Statement of Witness 1
_____________
Witness Name & Contact 2
_____________
Statement of Witness 2
_____________
Photographs/Sketches Attached (Yes/No)
_____________
Reference to CCTV footage (if any)
_____________
6Root Cause Analysis (RCA)4 fields
Unsafe Act (e.g., Not using PPE, Improper procedure, Operating without authority)
_____________
Unsafe Condition (e.g., Defective tool, Poor housekeeping, Inadequate lighting, Unguarded opening)
_____________
Contributing Systemic Factors (e.g., Lack of training, Inadequate supervision, Poor JSA/HIRA)
_____________
Primary Root Cause
_____________
7Corrective and Preventive Actions (CAPA)6 fields
Immediate Corrective Action Taken
_____________
Long-term Preventive Action Proposed
_____________
Responsibility for Action (Name/Designation)
_____________
Target Completion Date
_____________
Status (Open/Closed)
_____________
Verification of Effectiveness
_____________
💡 Sample filled excerpt
Incident Type: First Aid Case. Affected Person: Suresh Yadav, Helper. Nature of Injury: Minor cut on right hand. Immediate Action: First aid provided at site clinic, antiseptic dressing applied. Root Cause (Unsafe Act): Worker was manually handling sharp-edged rebar offcuts without using hand gloves.
⚖ Compliance notes
- Fulfills reporting requirements under the Building and Other Construction Workers (BOCW) Act, 1996, specifically Section 39 (Notice of certain accidents).
- Mandatory for submission to the Inspector (DISH / Labour Dept) for fatal or serious accidents as per state rules (e.g., Form XVII under Maharashtra BOCW Rules).
- Serves as primary evidence for claims under The Employee's Compensation Act, 1923 and for ESIC procedures.
- Essential documentation for internal/external safety audits (ISO 45001) and client/PMC reviews.