Volume-II of IV - GAIL

ANNEXURE-B
Format-4
4.0 SUPPLEMENTARY ACCIDENT & INVESTIGATION REPORT
Project:_____________________ Supplementary to Report No:
_________
(Copy enclosed)
Site:________________________ Date:_______________________
Contractor:______________________
NAME OF THE INJURED …………………………………………………………………………….
FATHER’S NAME…………………………………………………………………………………...
SUB-CONTRACTOR M/S……………………………………………………………………………...
DATE & TIME OF ACCIDENT………………………………………………………………………
LOCATION……………………………………………………………………………………………
BRIEF DESCRIPTION & CAUSE OF A ACCIDENT
NATURAL OF INJURY/DAMAGE
COMMENTS FROM MEDICAL PRACTITIONER WHO ATTENDED THE VICTIM/INJURED
SUGGESTED IMPROVEMENT IN THE WORKING CONDITION IF ANY
LOSS OF MANHOURS AND IMPACT ON SITE WORKS
ANY OTHER COMMENT BY SAFTEY OFFICER.
Date : __/__/__/ SIGNATURE OF
CONTRACTOR
WITH SEAL
To : OWNER…………………………… 1 COPY
: RCM/SITE-IN-CHARGE, MECON 1 COPY
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