ANNEXURE 1
OCCUPATIONAL HEALTH AND SAFETY ACT, 1993
(ACT NO 85 OF 1993)
REGULATION 9 OF THE GENERAL ADMINISTRATIVE REGULATIONS
RECORDING AND INVESTIGATION OF INCIDENTS
A. RECORDING OF INCIDENT
1. Name of employer
2. Name of affected person
3. Identity number of affected person
4. Date of incident 5. Time of incident
6. Part of body affected Head or Eye Trunk Finger Hand
Neck
Arm Foot Leg Internal Multiple
7. Effect on person Sprains Contusion or Fractures Burns Amputation
or strains wounds
Electric Asphyxiation Unconsciou Poisoning Occupational
shock sness Disease
8. Expected period of 0-13 days 2-4 >4-16 >16-52 >52 weeks or Killed
disablement weeks weeks weeks permanent
disablement
9. Description of occupational disease
10. Machine/process involved/type of work performed/exposure**
11. Was the incident reported to the Compensation Commissioner and Provincial Director?
Yes No
*
12. Was the incident reported to the police?
Yes No
13. SAPS office and reference
*
to be completed in case of a fatal incident
** in case of a hazardous chemical substance, indicate substance exposed to
B. INVESTIGATION OF THE ABOVE INCIDENT BY A PERSON DESIGNATED THERETO
1. Name of investigator
2. Date of investigation
3. Designation of investigator
4. Short description of incident
5. Suspected cause of incident
6. Recommended steps to prevent a recurrence
Signature of Investigator Date
C. ACTION TAKEN BY EMPLOYER TO PREVENT THE RECURRENCE OF A SIMILAR
INCIDENT
Signature of employer Date
D. REMARKS BY HEALTH AND SAFETY COMMITTEE
Remarks
Signature of Chairperson of Health and Safety Committee Date