INCIDENT INVESTIGATION REPORT (To be submitted to the HSEQ Corporate Office within 7 days of incident.) 1. Project Information: Project Name: Click here to enter text. Report No.: Click here to enter text. Project Location: Click here to enter text. Property No.: Click here to enter text. ☐ Fatality ☐ Major Incident ☐ Minor Incident 2. Describe the Incident in detail: Answer who, what, why, where, when & how in this section: (Attach additional pages if required) Click here to enter text. ☐ Photos Attached 3. Incident Root Causes: Describe direct, indirect & root cause: (Attach additional pages if required) Click here to enter text. 4. Key Corrective Actions to Prevent Recurrence: Describe the corrective actions with timeframe: (Attach additional pages if required) Click here to enter text. 5. Key Corrections Taken Immediately after the Incident: Attach additional pages if more space is required: Click here to enter text. 6. Witnesses: I declare that I witnessed the incident and the information provided above is true, correct and complete. No. Name Designation Signature Date 1. Click here to enter text. Click here to enter text. Click here to enter text. 2. Click here to enter text. Click here to enter text. Click here to enter text. 7. Incident Information: Initial Incident Report No.: Click here to enter text. Date Reported: Click here to enter text. Date of Incident: Click here to enter text. Time of Incident: Click here to enter text. Type of Incident: ☐ Near Miss ☐ Major Environmental Incident ☐ Serious Dangerous Occurrence ☐ Equipment / Property Damage ☐ Medical Treatment Case (MTC) ☐ Restricted Work Case (RWC) ☐ Lost Workday Case (LWC) ☐ Serious Occupational Illness/Disease ☐ Class 1 Injuries ☐ Permanent Partial Disability (PPD) ☐ Permanent Total Disability (PTD) ☐ Fatality (F) Recordkeeping: ☐ Reportable ☐ Recordable Incident Location on Site: Click here to enter text. Applicable Reports: ☐ Police ☐ Medical ☐ Other (Specify) Click here to enter text. Attached: ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 8. Injured Person’s Personal Details: In case of an incident with more than one injured person, complete the information for each person using separate forms. Name: Click here to enter text. Occupation: Click here to enter text. Company: Click here to enter text. MB / Oracle No.: Click here to enter text. Nationality: Click here to enter text. Date of Birth: Click here to enter text. Passport Number: Click here to enter text. Length of Service: Click here to enter text. Gender: ☐ Male ☐ Female Labour Card No.: Click here to enter text. 9. Incident Causes Details: To be supported with factual evidence Immediate Cause (Unsafe Acts) ☐ Failure to secure ☐ Failure to warn ☐ Removing / Defeating Safety Devices ☐

1. Page 1 of 6 Form # HSEQ-IIR (Rev 9 – Mar 23)
INCIDENT INVESTIGATION REPORT
(To be submitted to the HSEQ Corporate Office within 7 days of incident.)
1. Project Information:
Project Name: Click here to enter text. Report No.: Click here to enter text.
Project Location: Click here to enter text. Property No.: Click here to enter text.
☐ Fatality ☐ Major Incident ☐ Minor Incident
2. Describe the Incident in detail:
Answer who, what, why, where, when & how in this section: (Attach additional pages if required)
Click here to enter text.
☐ Photos Attached
3. Incident Root Causes:
Describe direct, indirect & root cause: (Attach additional pages if required)
Click here to enter text.
4. Key Corrective Actions to Prevent Recurrence:
Describe the corrective actions with timeframe: (Attach additional pages if required)
Click here to enter text.
5. Key Corrections Taken Immediately after the Incident:
Attach additional pages if more space is required:
Click here to enter text.
6. Witnesses:
I declare that I witnessed the incident and the information provided above is true, correct and complete.
No. Name Designation Signature Date
1. Click here to enter text. Click here to enter text.
Click here to
enter text.
2. Click here to enter text. Click here to enter text.
Click here to
enter text.

2. Page 2 of 6 Form # HSEQ-IIR (Rev 9 – Mar 23)
7. Incident Information:
Initial Incident Report No.: Click here to enter text. Date Reported: Click here to enter text.
Date of Incident: Click here to enter text. Time of Incident: Click here to enter text.
Type of Incident: ☐ Near Miss
☐ Major Environmental Incident
☐ Serious Dangerous Occurrence
☐ Equipment / Property Damage
☐ Medical Treatment Case (MTC)
☐ Restricted Work Case (RWC)
☐ Lost Workday Case (LWC)
☐ Serious Occupational Illness/Disease
☐ Class 1 Injuries
☐ Permanent Partial Disability (PPD)
☐ Permanent Total Disability (PTD)
☐ Fatality (F)
Recordkeeping: ☐ Reportable ☐ Recordable
Incident Location on Site: Click here to enter text.
Applicable Reports: ☐ Police ☐ Medical ☐ Other (Specify)
Click here to enter text.
Attached: ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
8. Injured Person’s Personal Details:
In case of an incident with more than one injured person, complete the information for each person using
separate forms.
Name: Click here to enter text. Occupation: Click here to enter text.
Company: Click here to enter text. MB / Oracle No.: Click here to enter text.
Nationality: Click here to enter text. Date of Birth: Click here to enter text.
Passport Number: Click here to enter text. Length of Service: Click here to enter text.
Gender: ☐ Male ☐ Female Labour Card No.: Click here to enter text.
9. Incident Causes Details: To be supported with factual evidence
Immediate Cause
(Unsafe Acts)
☐ Failure to secure
☐ Failure to warn
☐ Removing / Defeating Safety
Devices
☐ Failure to use PPE properly
☐ Operating at improper speed
☐ Lack of awareness/knowledge
☐ Lack of attention / concentration
☐ Violation / taking shortcuts
☐ Operating equipment without authority
☐ Servicing equipment in operation
☐ Using defective equipment / tools
☐ Using equipment improperly
☐ Improper lifting / loading / placement
☐ Improper position for task
☐ Horseplay (practical joke with harmful
impacts)
☐ Others (Specify)
Click here to enter text.
Immediate Cause
(Unsafe Conditions)
☐ Inadequate guards or barriers
☐ Inadequate warning system or
notice
☐ Inadequate ventilation
☐ Fire and explosion hazards
☐ High / Low temperature exposure
☐ Hazardous gases / dusts / vapors /
fumes
☐ Defective tools, equipment or
materials
☐ Inadequate or improper protective
equipment
☐ Inadequate or excess illumination
☐ Congestion/ restricted action/ poor
access
☐ Poor housekeeping, disorder
☐ Excessive noise exposure
☐ Radiation exposure
☐ Equipment failure
☐ Others (Specify) Click here to enter text.

3. Page 3 of 6 Form # HSEQ-IIR (Rev 9 – Mar 23)
Root Causes
(Personal Factor)
☐ Physical Capability
(Any sensory deficiency, inadequate
size or strength or physical disabilities)
☐ Mental State
(Poor judgement, memory failure,
poor condition, fears or emotional
disturbance)
☐ Behavior
(Save time, avoids discomfort,
improper supervisory, inadequate
disciplinary process or inappropriate
aggression)
☐ Physical Condition
(Previous injury/illness, fatigue, blood sugar
or impairment due to drugs)
☐ Skill Level
(Inadequate required skill, lack of coaching on
skill or infrequent performance of skill)
☐ Mental Stress
(Frustration, confusion/conflicting directions,
emotional overload, extreme meaningless
activities or concentration/judgement
demands)
☐ Others (Specify)
Click here to enter text.
Root Causes
(System Factor)
☐ Inadequate training / knowledge
transfer
☐ Inadequate / Missing Work
Procedures (Method Statements)
☐ Inadequate Purchasing/Material
handling
☐ Inadequate Tools/Equipment
☐ Inadequate Risk Assessment/
Management
☐ Inadequate Contractor
Management
☐ Inadequate Management of
Change
☐ Inadequate Leadership Supervision
☐ Inadequate Incident Investigation /
Analysis
☐ Inadequate Engineering/ Design/
Controls
☐ Inadequate Maintenance
☐ Inadequate Communication
☐ Inadequate Planned Inspections
☐ Inadequate Emergency Response Plan
☐ Others (Specify)
Click here to enter text.
10. Injury Details: To be supported with diagnosis by Licensed Health Care Professional and/or Medical
Report
Nature of Injury /
Illness:
☐ Abrasions/Bruising
☐ Burn
☐ Cuts/ Laceration/ Open Wound
☐ Electric Shock
☐ Foreign Body in Eye
☐ Heat Related Illness
☐ Nerve/ Spinal Cord Injury
☐ Poisoning/ Toxic Effect –
Inhalation
☐ Poisoning/ Toxic Effect – Ingestion
☐ Skin Irritation/ Disease
☐ Amputation - Traumatic
☐ Concussion
☐ Hearing Loss / Deafness
☐ Foreign Body under Skin
☐ Hearing Loss / Deafness
☐ Foreign Body under Skin
☐ Infectious Disease
☐ Occupational Illness / Disease
☐ Psychological (Stress)
☐ Strain / Sprain
☐ Bite / Sting
☐ Crush / Internal Injury
☐ Dislocation
☐ Fracture
☐ Hernia
☐ Musculoskeletal Disorder – Chronic / RSI
☐ Respiratory Disease
☐ Others (Specify)
Click here to enter text.
Mechanism of
Injury / Illness:
☐ Bite / Sting
☐ Chemicals/ Substances/ Radiation
☐ Extreme Temperature/ Fire
☐ Hit by moving object/ Crush/
Vehicle
☐ Penetrating Injury (needle stick, puncture
wound)
☐ Slip, Trip and Fall
☐ Cave-In or Collapse
☐ Dust / Fumes / Gases

4. Page 4 of 6 Form # HSEQ-IIR (Rev 9 – Mar 23)
☐ Occupational Violence
☐ Repetitive Motion
☐ Struck by Falling Object
☐ Biological Factors
☐ Drowning / Submersion
☐ Electricity
☐ Manual Handling
☐ Equipment / Property Damage
☐ Fall from Height
☐ Mental Stress
☐ Sound / Pressure
☐ Other Mechanism (Specify)
Click here to enter text.
Agency / Source of
Injury/Illness:
☐ Animal / Human
☐ Fixed Machinery /Plant
☐ Mobile Plant / Equipment
☐ Powered Equipment / Tools/
Appliances
☐ Sharps/ Scalpels/ Needles/ etc.
☐ Confined Space
☐ Infectious Agent
☐ Non-Powered Equipment/ Tools/
Appliances
☐ Road Transport / Vehicles
☐ Trench or Excavations
☐ Environmental Conditions
☐ Materials or Chemical Substances
☐ Scaffolding or Ladders
☐ Others (Specify)
Click here to enter text.
Bodily
Location:
☐ Head/ Neck ☐ Cervical Spine
☐ Face (excluding
eye)
☐ Neck
☐ Ear
☐ Forehead
☐ Nose
☐ Eye
☐ Mouth
☐ Scalp / Skull
☐ Trunk ☐ Abdomen
☐ Pelvis
☐ Back
☐ Spine
☒ Genitals
☐ Thorax
☐ Upper Extremity ☐ Clavicle (Collar
Bone)
☐ Forearm
☐ Thumb
☐ Elbow
☐ Hand
☐ Upper Arm
☐ Fingers (other
than Thumbs)
☐ Shoulder
☐ Wrist
☐ Lower Extremity ☐ Ankle
☐ Hip / Groin
☐ Thigh
☐ Buttocks
☐ Knee
☐ Toes
☐ Foot
☐ Lower Leg
☐ Internal Organs ☐ Arteries
☐ Intestines
☐ Lungs
☐ Brain
☐ Kidney
☐ Spleen
☐ Heart
☐ Liver
☐ Stomach
☐ General ☐ Heat Related ☐ Occupational
Illness
☐ Others (Specify)
Click here to enter
text.
11. Incident Cost: (Appropriate/Best Estimate)
No. Item / Area Amount (AED)
1. ☐ Injury Cost (Treatment, Hospital, Transport, Insurance, etc.)
2. ☐
Legal Cost (Compensation claims, judicial prosecutions, etc. – Federal Law
No. 8)
3. ☐
Productivity Cost (Business disruptions, Delays, Production loss/day,
Material, Salaries, etc.)
4. ☐
Asset Cost (Property, machinery, equipment, structure, material, vehicle,
etc. - Repair & Maintenance)
5. ☐
Asset Cost (Property, machinery, equipment, structure, material, vehicle,
etc. - Replacement)
6. ☐ Enforcement Action (Penalty Issued by Authority)
7. ☐ Incident Scene/Area restoration Cost
8. ☐ Other cost relevant to / associated with the incident

5. Page 5 of 6 Form # HSEQ-IIR (Rev 9 – Mar 23)
9. Total Cost
12. Risk Assessment:
Is the Method Statement & Risk Assessment reviewed and revised after the incident? ☐ Yes ☐ No
If NO, why not? Click here to enter text.
13. Risk Rating (considering/implementing the post incident corrective actions and controls:
Probability: ☐ Rare ☐ Possible ☐ Likely ☐ Often ☐ Frequent
Severity of Consequence: ☐ Insignificant ☐ Minor ☐ Moderate ☐ Major ☐ Catastrophic
Level of Residual Risk: ☐ Low ☐ Moderate ☐ High ☐ Extreme
14. Declaration by Injured Person (If applicable / possible):
I declare that all information provided in this document is true, correct and complete.
Name of Injured
Person or
Representative:
Click here to enter text.
Signature of
Injured Person
or
Representative:
Date: Click here to enter text.
15. Declaration by Investigation Team:
I declare that all information provided in this document is true, correct and complete.
No. Name Designation Signature Date
1. Click here to enter text. Click here to enter text.
Click here to
enter text.
2. Click here to enter text. Click here to enter text.
Click here to
enter text.
3. Click here to enter text. Click here to enter text.
Click here to
enter text.
4. Click here to enter text. Click here to enter text.
Click here to
enter text.
16. Attachments:
☐ Maps / Drawings
☐ Relevant Records (e.g. Training, Risk Assessment)
☐ Written witnesses statements
☐ Others (Specify)
Click here to enter text.

6. Page 6 of 6 Form # HSEQ-IIR (Rev 9 – Mar 23)
Report Prepared by: Reviewed by PD/PM (Manager In Charge):
Name : Click here to enter text. Name : Click here to enter text.
Designation: Click here to enter text. Designation: Click here to enter text.
Date: Click here to enter text. Date: Click here to enter text.
☐ Acknowledge that this incident has been/will be reported to relevant authorities
(if applicable).
☐ Acknowledge that copy of this report will be sent to Admin Dept.
☐ Acknowledge that copy of this report will be sent to Insurance Dept.
☐ For Abu Dhabi projects, copy of this report will be sent to GLA Manager
Signature: Signature:
Corporate Office Remarks:
NOTE: In case of changes in the status/severity of the injured person(s) the Corporate HSEQ Office shall be
notified.