Volume-II of IV - GAIL

ANNEXURE-B
Format-3
3.0 ACCIDENT REPORT
(To be submitted by Contractor after every accident within 2 hours of accident)
Name of Site:-_______________________
CONTRACTOR______________________
Report No:___________________
Date: _______________________
NAME OF THE
INJURED………………………………………………………………………………..
FATHER’S NAME………………………………………………………………………………………..
SUB-CONTRACTOR
M/S………………………………………………………………………………..
DATE & TIME OF ACCIDENT………………………………………………………………………….
LOCATION ………………………………………………………………………………………………
BRIEF DESCRIPTION OF ACCIDENT
CAUSE OF ACCIDENT
NATURE OF INJURY/DAMAGE
MEDICAL AID PROVIDED/ACTIONS TAKEN
INTIMATION TO LOCAL AUTHORITIES
DATE: SIGNATURE OF CONTRACTOR
WITH SEAL
To : OWNER………………………….. 1 COPY
: RCM/SITE-IN-CHARGE, MECON 1 COPY
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