Report number..................... Of the particular accident.

1. General data

(a) Name of the site

(b) Name and address of the manufacturer (Also state telophone/telex number)

(c)

(i) Registration number

(ii) Licence number

(As may have been allotted under any status applicable to the site, e.g. the Factories Act)

(d)

(i) Nature of industrial activity (Mention what is actually manufactured, stored etc.)

(ii) National Industrial Classification

1987 at the four digit level. ___________ ____________ ____________

Type of major accident

Explosion _________ Fire __________ Emission of dangerous Substance __________

Substance(s) Emmited _____________________________________________________

3. Description of the major accident

(a) Date, shift and hour of the accident

(b) Department/Section and exact place where the accident took place

(c) The process/operation undertaken in the Department/Section where the accident took place. (Attach a flow chart if necessary)

(d) The circumstances of the accident and the dangerous substance involved.

4. Emergency Measures taken and measures envisaged to be taken to alleviate short term effects of the accident.

5. Causes of the major accident.

Known (to be specified) _______________

6. Not known _______________

Information will be supplied as soon as possible _______________

7. Nature and extent of damage

(a) Within the establishment-casualties

…………………… Killed
…………………… Injured
…………………… Poisoned

Persons exposed to the major accident ______________________________

material damaged __________________________

danger is still present ______________________________

danger no longer exists ______________________________

(b) Outside the establishment casualties

…………………… Killed
…………………… Injured
…………………… Poisoned

Persons exposed to the major accident ______________________________

material damaged ______________________________

damage to environment ______________________________

the danger is still present ______________________________

the danger no longer exists ______________________________

7. Data available for assessing the effects of the accident on persons and environment.

8. Steps already taken or envisaged

(a) to alleviate medium or long term effects of the accident.

(b) to prevent recurrence of similar major accident

(c) Any other relevant information.