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Particulars of accident |
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a. |
Exact place where accident occurred |
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b. |
Date |
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c. |
Time |
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d. |
What the injured person was doing at the time of accident |
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e. |
Weather condition |
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f. |
How long employed by you for this particular job |
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g |
Particulars of equipment/machine/ tool involved and conditionof the same after the accident occurred.
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h. |
Brief description of the accident |
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| 2. |
Nature of injuries. |
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a. |
Fatal |
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b. |
Non-fatal |
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c. |
If non-fatal, state precisely the nature of injuries(describein detail the nature of injury, for instance fracture of rightarm, sprain etc.)
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d. |
First Aid: |
:Given |
Not given |
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e. |
If not, give the reasons |
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f. |
Name and designation of the person by whom first-aid was given |
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g. |
If admitted to hospital, name of the hospital |
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Address of the hospital |
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Name of the Doctor. |
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Phone No. |
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| 3. |
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Mode of transport used Ambulance/ any other mode (pleasespecify)
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| 4. |
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How much time was taken to shift the injured person |
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a. |
If very late, state the reasons |
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b. |
How the reporting was made ? |
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Phone / Special messenger letter/email/SMS |
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c. |
Who visited the accident site first and what action wasproposed by him?
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d. |
What are the actions taken for the investigation of theaccident by the employer ? (describe about photographs/ Videofilm/ measurements taken, etc.)
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| 5. |
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Particulars of persons giving witness. |
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a. |
Name |
Address |
Occupation |
Mobile No. |
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2. |
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3. |
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4. |
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| 6. |
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Particulars in case of fatal |
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Date/Time |
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Whether worker registered with Building and Other ConstructionWorkers' Welfare Board. If yes, give Registration Number &name of the Board
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| 7. |
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Dangerous Occurrences as covered under the Regulation No.(Give details)
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a. |
Collapse or failure of lifting appliances, hoist conveyors,etc.
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b. |
Collapse or subsidence of soil, any wall, floor, gallery etc. |
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c. |
Collapse of transmission towers, pipeline, bridges, etc. |
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d. |
Explosion of receiver, vessel, etc. |
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e |
Fire and explosion |
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f |
Spillage or leakage of hazardous substances |
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g |
Collapse, capsizing, toppling or collision of transportequipment
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h |
Leakage or release of harmful toxic gases at the constructionsite.
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i. |
Failure of lifting appliance, loose gear, hoist or building andother construction work machinery, transport equipment, etc.
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| 8. |
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Certificate from the Employer or authorized signatory. |
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