HSSE INCIDENT ANALYSIS FORM Employee ID(Required)Employee Name(Required)Position Description(Required)Phone Number(Required)Department(Required)CEO Office Section(Required)EM Section(Required)Operations Section(Required)HR , ADMIN & IT Section(Required)HSE Section(Required)Finance Section(Required)TS Section(Required)COD Section(Required)Form Number: 2025/TS/QA/HS/069 INCIDENT REF. NO.(Required)DEPARTMENT(Required) COD EMP FINANCE HR HSE QC 1A. INCIDENT CATEGORY(mark one)(Required) Minor Moderate Major 1B. TYPE OF INCIDENT(Required) Personal injury (8a) Fire/explosion (8b) Motor Vehicle Accident (8c) Asset damage (8d) Process incidents (8e) Damage to environment (8f) Other Near miss 2. TIME AND PLACE OF INCIDENTResponsible Department(Required)Location site(Required)Area(Required)Person Involved(Required)Date(Required) MM slash DD slash YYYY Time(Required) Hours : Minutes AM PM AM/PM 3. DESCRIPTION OF INCIDENT (continue on back of form or separate sheet if necessary)(Required)References Attached(Required) Sketch Photo Additional description Witness Interview Notes Other References Attached(Required) Sketch Photo Additional description Witness Interview Notes Other 4. WORK OPERATION (mark one box only)(Required) Construction/Scaffolding Lifting/Crane Ops Operations Transport Workshop Maintenance Warehousing Others Other Work Operation(Required)Sub-Activity (description)(Required) 5. INVOLVED FACTORSCompany Involved(Required)System/Facilities(Required)Hazardous Substance(s)(Required)6. NOTIFYING AND REPORTING(Required) Fire section notified Line management notified Incident analysis/ investigation completed Review panel required
