Date and Time of Accident

Location (Shaft/Area)

Specific Location at the Mining Site

Reporter Name

Job Title

Company Name

Phone number

Email

Name of Injured Employee

Incident Description

Provide a detailed account of the incident. Include events leading up to, during, and following the occurrence.

Witness Name 1

Phone number

Witness Name 2

Phone number

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Were there any injuries?

• Yes

• No

Description of Injuries or Damages

Describe the type and severity of injuries. Specify who was injured and their condition.

First Aid Given?

• Yes

• No

Medical Attention Needed?

• Yes

• No

Immediate Actions Taken

Describe actions taken to address the incident, such as evacuation, containment, or notification of emergency services.

Was the incident reported to a supervisor?

• Yes

• No

Supervisor Name

Phone Number

Additional Comments

Include any further information, suggestions, or recommendations to prevent future occurrences.