TRIE SSS prolieg cLiyjpasaira GOVERNMENT OF DUEAL Dros eactichiyt Weta tnt ‘SP06-ANNEUXRE IV A PRELIMINARY REPORT INCIDENT (ACCIDENT/NEAR MISS} {CONTRACTOR STAFF) To: Manager-Safety /Health, H&SS, DEWA Incident No. (To be filled H&SS DEWA) Fro 12/07/2020. Contract No. ...PO-3091800062.. ‘Thru: a) Consultant .......ssesssssessessessssee b) DEWA Executing Dept.: PTD.. la, Name, ID No. & Designation of the Victim/ involved with Accident ‘Near : ZAKIR KHAN JALAT KHAN, 784-1997-1587082-2, miss MATERIAL SUPPLY TRUCK, DRIVER, Contractor : KEC/AZTEC.. Signature & Dt.: 1b. Equipment’ Machinery/ Vehicle etc. MATERIAL, SUPPLY TRUCK involved in Accident / Near miss woes 2. Date, Time & Spot of Accident/Near : 12/07/2020.(3.00 pm Miss 3. Name, Designation & Tel. No. of :ASHARAF, SUPERVISOR, Direct Supervisor 00971555276986.. 4, What Happened? : AFTER UNLOADING OF POLYGROUT NS, DRIVER MOVED THE VEHICLE FORWARD WITHOUT NOTICING THE TEMPORARY ELECTRIC WIRES WHICH RESULTS IN FALLING OFF ELECTRICAL DISTRIBUTION BOARD AND BREAKING OF LIVE ELECTRIC WIRES WHICH IS HAVING THE POTENTIAL OF CAUSING ELECTRICAL HAZARDS.. 5. How It Happened? :DRIVERN.NEGLIGENCE 6. Area /Location/ Place of Happening © : NEAR SECURITY GATE, CARPENTARY WORK AREA.. i 7. Name of Witness :RAMESH PRASAD, SECURITY, AZTEC MIDDLE EAST,KES Bs (poling cya Stine commoner Sov Setenaasny sunray MAKHAZEN 132/11KV. SUBSTATION.. 8, Present Status of the Victim (Sick :RESUMED Leave/ Police Custody ‘Hospitalized DUTY.. /Resumed Duty) 9. Risk Assessment Carried out forthe Yes /No activity (If yes, pl. attach the copies). NB: Please Fax to 2857415 within 24 Hours of the Occurrence through DEWA executing department ‘SPO6-ANNEUXRE IVB. reliinary For- Contractor -H&SS, DEWA2014 FOLLOW UP REPORT INCIDENT (ACCIDENT/ NEARMISS) [Incident No. (CONTRACTOR STAFF) (Tobe filled H&SS DEWA) PART 1: To be filled by Contractor, Consultant & DEWA executing dept. as applicable. To: Manager- Safety/Health, H&SS, DEWA Ref. No... 2.22... CC: SM-H&S Contract No./ Contractor DEWA Dept. .. Name Of Person Involved LD.No. «5 Designation: Description of Incident (Additional sheet may be attached if required) a) Immediate Supervisor of Contractor b) Supervisor/Engineer of DEWA Name: TALNow oes Name Tel. Signature & Date. ..oeeeseseeeee Signature & Date ‘Comments & recommendation (Additional shest may be atiached ifrequired)= a) Contractor:w roliog cya seiin GOVERNMENT OF DUBAI Duel lectricyt Water Authority 'SPO6-ANNEUXRE IVB ames. ‘Signature & Date: Tar, b) Consuitant:. Name: . Tel csececsee ©) Sr. Manager (DEWA): Follow Up Form- Contractor ~ H&SS/2014 Page no 1 of 2 (CONTRACTOR STAFF) TO: DEWA Exec. Dept. Incident No. CC: SM-H&S Date: . Investigated By: (To be filled by H&SS, DEWA) _| Designation: Sign. & dt PART 2: Final comments & recommendation of Manager —Safety/Health, H&SS, DEWA:= OLOHd NOILVAYASHO SSIN AVAN