Form G2 - Non Serious Incident Investigation Report

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ADOSH-SF – Forms
Form G2 – Non Serious Incident Investigation Report – Version 4.0 – 15th July 2024 Page 1 of 5
Form G2
Appropriate Investigation to be completed as per Mechanism 11.0
All non-serious Incidents not requiring notification to SRA should be investigated and results recorded using this Form
(G2)
Part A – Incident Information
1. Reporting Entity Information
Name of Entity:
Sector: Classification
Code:
Registration Number:
Address of Entity:
Authorized Contact
Person:
Email
Address:
Telephone Number: Mobile
Number:
2. Incident involving 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:
☐ Restricted Work Case
☐ Medical Treatment Case
☐ First aid Injury
☐ Equipment / Property Damage
☐ Near-miss
4. Incident Details:
Brief description of the
main circumstances
leading to the Incident:
(Attach additional pages if
more space is required)
Incident Location on Site:
Incident Workplace
Address:
Medical Report: (If
applicable)

ADOSH-SF – Forms
Form G2 – Non Serious Incident Investigation Report – Version 4.0 – 15th July 2024 Page 2 of 5
Form G2
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,)
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 _____________________________

ADOSH-SF – Forms
Form G2 – Non Serious Incident Investigation Report – Version 4.0 – 15th July 2024 Page 3 of 5
Form G2
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____________________________
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

ADOSH-SF – Forms
Form G2 – Non Serious Incident Investigation Report – Version 4.0 – 15th July 2024 Page 4 of 5
Form G2
☐ 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: ______________
3. Actions Taken Immediately after the Incident :
(Attach additional pages if more space is required)
No. Actions: Responsibility
Date
Completed:
(DD/MM/YYYY)
1.
2.
3.
4. Incident Root Cause(s):
(Refer to Section 1. Attach additional pages if more space is required)
1.
2.
3.
5. Corrective Actions to Prevent Recurrence :
(Attach additional pages if more space is required)
No. Actions: Person Responsible: Target
Date(DD/MM/YYYY)
1.
2.
3.
6. 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 etc.)
7. ☐ Incident Scene / Area Restoration Cost (arrangements to make safe, cleanup,
etc.)
8. ☐ Other Cost relevant to / associated with the Incident
9. Total Cost

ADOSH-SF – Forms
Form G2 – Non Serious Incident Investigation Report – Version 4.0 – 15th July 2024 Page 5 of 5
Form G2
7. 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
8. Declaration by Injured Person (If applicable)
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) _____ / _____ / _____
9. Reviews & Approvals:
☐ 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.)
☐ 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 Investigation Team Leader Signature of OSH Manager or Equivalent
Date (DD/MM/YYYY) _____ / _____ / _____ Date (DD/MM/YYYY) _____ / _____ / _____