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Critical Incident Report Form
"I need a Critical Incident Report Form for our manufacturing facility that focuses on machinery accidents and chemical spills, with specific sections for equipment damage assessment and environmental impact reporting, compliant with Philippine DOLE regulations."
1. Incident Identifier: Unique reference number, date, time, and location of the incident
2. Reporter Information: Details of the person completing the report including name, position, contact information, and relationship to the incident
3. Incident Description: Detailed account of what happened, including sequence of events, immediate causes, and contributing factors
4. Persons Involved: Information about all individuals involved, including victims, witnesses, and other relevant parties
5. Immediate Actions Taken: Description of immediate response actions, including emergency measures and notifications made
6. Injuries/Damage Assessment: Details of any injuries to persons or damage to property/equipment
7. Initial Risk Assessment: Evaluation of the severity and potential consequences of the incident
8. Immediate Notifications Made: List of authorities, management, or other parties notified of the incident
9. Follow-up Actions Required: Immediate and long-term actions needed to address the incident and prevent recurrence
1. Medical Response Details: Used when incident involves injuries requiring medical attention, including treatment provided and healthcare facilities involved
2. Environmental Impact: Required when incident involves environmental hazards or damage
3. Equipment/Property Damage Details: Used when incident involves damage to physical assets or equipment
4. Security Breach Information: Required for incidents involving security violations or unauthorized access
5. Media/Public Relations Impact: Used when incident has potential public relations implications or media attention
6. Worker's Compensation Details: Required when incident involves employee injuries that may lead to compensation claims
7. Legal Implications: Used when incident may have legal consequences or require legal reporting
1. Witness Statements: Forms and collected statements from witnesses to the incident
2. Photographic Evidence: Photos or visual documentation of the incident scene, damages, or injuries
3. Incident Scene Diagram: Sketches or diagrams showing the layout and relevant details of where the incident occurred
4. Supporting Documentation: Relevant certificates, licenses, maintenance records, or other documents related to the incident
5. Medical Reports: Copies of medical assessments or treatment records if applicable
6. Risk Assessment Forms: Completed risk assessment forms related to the activity during which the incident occurred
7. Investigation Checklist: Standard checklist for ensuring all necessary investigation steps are completed
Authors
Near Miss
Affected Party
Reporting Person
First Responder
Immediate Action
Root Cause
Contributing Factor
Corrective Action
Preventive Measure
Severity Level
Material Damage
Workplace
Safety Officer
Emergency Response
Hazard
Risk Level
Personal Injury
Property Damage
Environmental Impact
Witness Statement
Investigation Period
Follow-up Action
Notification Period
Regulatory Authority
Safety Protocol
Work Stoppage
Medical Treatment
Lost Time Incident
Incident Scene
Personal Information
Data Privacy
Health and Safety
Incident Description
Emergency Response
Risk Assessment
Reporting Requirements
Medical Information
Witness Statement
Property Damage
Environmental Impact
Regulatory Compliance
Investigation Process
Evidence Documentation
Corrective Actions
Follow-up Procedures
Confidentiality
Legal Disclosure
Record Keeping
Notification Requirements
Authority and Signatures
Document Retention
Healthcare
Manufacturing
Construction
Education
Transportation
Hospitality
Mining
Energy
Retail
Financial Services
Information Technology
Logistics
Chemical Industry
Food and Beverage
Public Sector
Maritime
Operations
Health and Safety
Human Resources
Risk Management
Security
Quality Assurance
Compliance
Emergency Response
Facilities Management
Environmental Health
Legal
Medical Services
Senior Management
Safety Manager
Risk Management Officer
Department Supervisor
Facility Manager
Human Resources Director
Operations Manager
Security Officer
Quality Assurance Manager
Environmental Health and Safety Coordinator
Compliance Officer
Site Supervisor
Shift Leader
Department Head
Emergency Response Coordinator
Health and Safety Representative
Plant Manager
Project Manager
Chief Operating Officer
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