Form G1 - Serious Incident Investigation

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ADOSH-SF – Forms
Form G1 – Serious Incident Investigation – Version 4.0 – 15th July 2024 Page 1 of 6
Form G1
Appropriate Investigation to be completed as per Mechanism 11.0
To be completed and submitted to SRA as soon as practicable
Maximum 30 Calendar Days from Date of Incident - For all Serious Incidents notified to SRA by Form G
Reporting To: Reporting Date:
(DD/MM/YYYY)
Part A – Incident Information (as notified in Form G)
1. Reporting Entity Information: Incident No. (for official use by SRA)
Name of Entity:
Sector: Classification Code:
Registration Number:
Address of Entity:
Authorized Contact
Person: Email Address:
Telephone Number: Mobile Number:
2. Reporting on behalf of a Non-Nominated Contractor (hired by or working for Entity but
not Nominated currently with any concerned SRA/does not fall under any current Sector): ☐ Yes ☐ No
Name of Contractor:
Type of Business:
Address:
3. Incident Information:
Date of Incident:
(DD/MM/YYYY) Time (24 hr):
Incident Type:
Lost Time Injuries
☐ Fatality
☐ Permanent Total Disability
☐ Permanent Partial Disability
☐ Lost Workdays Injury
☐ Lost Workdays Occupational Illness
☐ Serious Dangerous Occurrence
4. Incident Details:
Brief description of the
main circumstances
leading to the Incident:
(Attach additional pages if
requires)
Incident Location on Site:
Incident Workplace
Address
Region where incident
occurred: ☐ Abu Dhabi ☐ Al Ain ☐ Western region
Applicable Reports: ☐ Police ☐ Medical ☐ Investigation
report and Photos ☐ Other (Specify)
Attached: ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
5. Injured Person’s Personal Details (For Injuries):
In case of an incident with more than one injured person, complete the information for each person using separate forms
Name: Occupation:
Relationship with Entity: ☐ Entity Employee ☐ Contractor Employee ☐ Other Person (e.g. Visitor,)

ADOSH-SF – Forms
Form G1 – Serious Incident Investigation – Version 4.0 – 15th July 2024 Page 2 of 6
Form G1
Nationality: Date of Birth:
Passport Number: Length of Service: ____Years __ Months
Contact Phone Number: Gender: ☐ Male ☐ Female
Part B – Incident Investigation Summary
1. Incident Causes Details: To be supported with the incident investigation report
Immediate Cause
(Unsafe Act)
☐ Failure to secure ☐ Operating equipment without authority
☐ Failure to warn ☐ Servicing equipment in operation
☐ Removing / Defeating Safety Devices ☐ Using defective equipment / tools
☐ Failure to use PPE properly ☐ Using equipment improperly
☐ Operating at improper speed ☐ Improper lifting/ loading/ placement
☐ Lack of awareness / knowledge ☐ Improper position for task
☐ Lack of attention / concentration ☐ Horseplay (practical joke with harmful impacts)
☐ Violation / taking shortcuts ☐ Others __________________________
Immediate Cause
(Unsafe Conditions)
☐ Inadequate guards or barriers ☐ Inadequate or improper protective equipment
☐ Inadequate warning system or notice ☐ Inadequate or excess illumination
☐ Inadequate ventilation ☐ Congestion/ restricted action/ poor access
☐ Fire and explosion hazards ☐ Poor housekeeping, disorder
☐ High / Low temperature exposure ☐ Excessive noise exposure
☐ Hazardous gases/dusts/vapors/fumes ☐ Radiation exposure
☐ Defective tools, equipment or materials ☐ Equipment failure
☐ Others ____________________________
Root Causes
(Personal factor)
☐ Physical Capability
(Any sensory deficiency, Inadequate size or
strength or physical disabilities)
☐ Physical Condition
(previous injury/illness, Fatigue, blood sugar or
Impairment due to drugs)
☐ Mental State
(poor judgment, memory failure, poor
condition, fears or emotional disturbance)
☐ Skill Level
(Inadequate required skill, lack of coaching on
skill or infrequent performance of skill)
☐ Behavior
(save time, avoids discomfort, improper
supervisory, inadequate disciplinary process
or inappropriate aggression)
☐ Mental Stress
(Frustration, confusion/conflicting directions,
emotional overload, extreme meaningless
activities or concentration/judgment demands)
☐ Human Error ☐ Others _______________________________
Root Causes
(System Factor)
☐ Inadequate Training / Knowledge transfer ☐ Inadequate Leadership Supervision
☐ Inadequate / Missing Work Procedures (SoP) ☐ Inadequate Incident Investigation / Analysis
☐ Inadequate Purchasing/Material handling ☐ Inadequate Engineering / Design / Controls
☐ Inadequate Tools/Equipment ☐ Inadequate Maintenance
☐ Inadequate Risk Assessment / Management ☐ Inadequate Communication
☐ Inadequate Contractor Management ☐ Inadequate Planned Inspections
☐ Inadequate Management of Change ☐ Inadequate Emergency Response Plan
☐ Others_________________________

ADOSH-SF – Forms
Form G1 – Serious Incident Investigation – Version 4.0 – 15th July 2024 Page 3 of 6
Form G1
2. Injury Details:
To be supported with diagnosis by Licensed Health Care Professional and/or Medical Report
Nature of Injury / Illness:
☐ Abrasions / Bruising ☐ Amputation - Traumatic ☐ Bite / Sting
☐ Burn ☐ Concussion ☐ Crush / Internal Injury
☐ Cuts/ Laceration / Open
Wound ☐ Hearing Loss / Deafness ☐ Dislocation
☐ Electric Shock ☐ Foreign Body under Skin ☐ Fracture
☐ Foreign Body in Eye ☐ Infectious Disease ☐ Hernia
☐ Heat Related Illness ☐ Occupational Illness /
Disease
☐ Musculoskeletal Disorder -
Chronic / RSI
☐ Nerve / Spinal Cord Injury ☐ Psychological (Stress) ☐ Poisoning / Toxic Effect -
Ingestion
☐ Poisoning / Toxic Effect –
Inhalation ☐ Strain / Sprain ☐ Respiratory Disease
☐ Skin Irritation / Disease ☐ Other ________________ ☐ Other _____________
Mechanism of Injury /
Illness:
☐ Bite / Sting ☐ Biological Factors ☐ Cave-In or Collapse
☐ Chemicals / Substances /
Radiation ☐ Drowning / Submersion ☐ Dust / Fumes / Gases
☐ Equipment / Property Damage
☐ Extreme Temperature /
Fire ☐ Electricity ☐ Fall from Height
☐ Hit by Moving Object /
Crush / Vehicle ☐ Manual Handling ☐ Mental Stress
☐ Occupational Violence ☐ Penetrating Injury (needle stick, puncture wound)
☐ Repetitive Motion ☐ Slip, Trip and Fall ☐ Sound / Pressure
☐ Struck by Falling Object ☐ Other Unspecified Mechanism:
Agency / Source of
Injury / Illness:
☐ Animal / Human ☐ Confined Space ☐ Environmental Conditions
☐ Fixed Machinery / Plant ☐ Infectious Agent ☐ Materials or Chemical
Substances
☐ Mobile Plant / Equipment ☐ Non-Powered Equipment / Tools / Appliances
☐ Powered Equipment / Tools /
Appliances ☐ Road Transport / Vehicles ☐ Scaffolding or Ladders
☐ Sharps / Scalpels / Needles /
etc. ☐ Trench or Excavations ☐ Other
Bodily
Location:
☐ Head / Neck
☐ Cervical Spine ☐ Ear ☐ Eye
☐ Face (excluding eye) ☐ Forehead ☐ Mouth
☐ Neck ☐ Nose ☐ Scalp / Skull
☐ Trunk ☐ Abdomen ☐ Back ☐ Genitals
☐ Pelvis ☐ Spine ☐ Thorax
☐ Upper
Extremity
☐ Clavicle (Collar Bone) ☐ Elbow ☐ Fingers (other than Thumbs)
☐ Forearm ☐ Hand ☐ Shoulder
☐ Thumb ☐ Upper Arm ☐ Wrist
☐ Lower
Extremity
☐ Ankle ☐ Buttocks ☐ Foot
☐ Hip / Groin ☐ Knee ☐ Lower Leg
☐ Thigh ☐ Toes
☐ Internal
Organs
☐ Arteries ☐ Brain ☐ Heart
☐ Intestines ☐ Kidney ☐ Liver
☐ Lungs ☐ Spleen ☐ Stomach
☐ General ☐ Heat Related ☐ Occupational Illness ☐ Other:

ADOSH-SF – Forms
Form G1 – Serious Incident Investigation – Version 4.0 – 15th July 2024 Page 4 of 6
Form G1
3. Additional Information:
(additional information to complete the investigation as required by clause 5.4 of ADOSH-SF Mechanism 11.0 - to
include information not already covered by Form G1.)
Max word count 200 words, further information to be provided in the form of an investigation report.
4. Actions Taken Immediately after the Incident:
(Attach additional pages if more space is required)
No. Actions Responsibility Date Completed:
1.
2.
3.
5. Incident Root Cause(s):
(Refer to Section 1. Attach additional pages if more space is required)
1.
2.
3.
6. Corrective Actions to prevent Recurrence:
(Attach additional pages if more space is required)
No. Actions: Person Responsible: Target Date
1.
2.
3.
7. Incident Cost:
(Approximate / Best Estimate)
No. Item / Area Amount (Dhs.)
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, Vehicle, etc. – Repair & Maintenance)
5. ☐ Asset Cost (Property, Machinery, Equipment, Structure, Material, Vehicle, etc. – Replacement)
6. ☐ Enforcement Action (Penalty Issued by Authority)

ADOSH-SF – Forms
Form G1 – Serious Incident Investigation – Version 4.0 – 15th July 2024 Page 5 of 6
Form G1
7. ☐ Incident Scene / Area Restoration Cost (arrangements to making safe, cleanup, etc.)
8. ☐ Other Cost relevant to / associated with the Incident
9. Total Cost
8. Risk Assessment:
( considering / implementing the post incident corrective actions and controls): Refer to ADOSH-SF Technical Guideline on
Process of Risk Management
Probability: ☐ Rare ☐ Possible ☐ Likely ☐ Often ☐ Frequent
Severity of Consequence: ☐ Insignificant ☐ Minor ☐ Moderate ☐ Major ☐ Catastrophic
Level of Residual Risk: ☐ Low ☐ Moderate ☐ High ☐ Extreme
9. 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:
Signature of Injured
Person or
Representative:
Date :
(DD/MM/YYYY)
Declaration by Reporting Entity:
☐ I declare that all information provided in this document is true, correct and complete.
☐ Complete investigation report attached – as per Mechanism 11.0 – Incident Notification, Investigation and Reporting
☐ Relevant evidence included / attached to report (e.g. Copies of Relevant Procedures, Permits to Work, Photos, Drawings, MSDS,
Copy of Police Report, Copy of Medical Report, Interviews, etc.)
☐ I declare that corrective actions listed in this form and/or the attached investigation report will be fully implemented in a timely
manner
Incident Investigation Status: ☐ Closed – Completed ☐ Report attached
Signature of the CEO / MD:
(Top Manager)
Official
Stamp:
Date : (DD/MM/YYYY)

ADOSH-SF – Forms
Form G1 – Serious Incident Investigation – Version 4.0 – 15th July 2024 Page 6 of 6
Form G1
Official Use by SRA
Requires Reporting to ADPHC  Yes  No Requires SRA
Investigation / Follow-up  Yes  No
Remarks:
Relevant Authority Stamp Entered into Database by:
Name:
Signature:
Date: (DD/MM/YYYY)
Reviewed by:
Name:
Signature:
Date: (DD/MM/YYYY)
Note: Personal information will not be disclosed to other parties without entity’s consent unless required to do so by law