Amtek Railcar Industries Pvt Ltd

Report of Accident / Near Miss

Format No : FM/OHS/4532
Revision

Date of Investigation:

: 01

Date of Receipt:

1. Department in which accident / near miss occurred

2. Name of injured person / Who has observed the near

:
:

miss
3. Designation
4. Date and hour of accident / near miss
5. Hour at which he started work on the day of the

:
:
:

accident / near miss

6. (a) Cause of accident / near miss

i)

What was he doing

ii)

How did it happen

iii)

What stuck him

iv)

Is he given any protective equipment

v)

Was he using the same

vi)

If protective equipment is not provided, what

steps you recommend to avoid such accident / near

miss
vii)

:
What other alternative / modification you

recommend

viii)
Was work permit issued
(b) Name of machine and part caused accident / near

miss
(c) State whether it was moved by mechanical power at

the time of accident / near miss?

i)

Is it due to fault in machine

ii)

Is guard provided?

iii)

What steps you recommend to avoid

recurrence?
7. Described in details nature and extent of injury i.e.,

fetal, loss of fingers etc.

8. If the accident is not fatal, whether injured person is

likely to be disable for 48 hours

9. Under whose treatment is the injured person?

Signature of Supervisor

Signature of DH