accident information report
SAIL/SALEM STEEL PLA NT
INJURY ON WORK
(Contractor’s Employees)
1. Name of the Firm :
2. Name of the Contractor :
3. Name of the Deptt.
(Awarding contract) :
4. Name of the injured person :
5. Designation, & age, Gate pass No.:
6. Date & Time of accident :
7. Area where accident happened :
8. Exact place of occurrence :
9. Eye witness(name & designation :
With gate pass No.)
10. Wages :
11. Brief account of the accident :
12. Nature of injury :
Date: Signature of the Contractor/Contractor’s Engineer
Name:
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