APPENDIX C ACCIDENT REPORT FORM

SUBMITTED BY: Amardep Singh INJURY REPORT Minor Injioury in my Left anckel DATE OF INJURY: NAME OF INVOLVED PERSON TYPE OF EMPLOYEE: JOB FUNCTION/ DEPARTMENT SSE DATE SUBMITTED:

____19/08/11__________

TIME: _7:30_________ __Amardeep Singh______________________ SEX: AGE:. SANOFI-AVENTIS CONTRACTOR . Head Quarter:

Male

Approx time of service with 4 month sanofi-aventis TYPE OF ACCIDENT Fall-slip-trip yes Fall from a height Electric shock Other (describe) PARTS OF THE BODY AFFECTED Head Eyes Back Feet yes DESCRIPTION OF ACCIDENT :

Jammu Whether injured person was on : official duty official duty / personal work / leave (holiday or vacation) Motor Vehicle Accident Exposure to chemical, physical and biological agents Burn (hot, cold) Arms Internal Hands Others Trunk Legs

Helmet /Seatbelt in use _____Turbon_____(Yes/No) Condition of Road (bad /slippery/rainy): Weather Condition (Fair/Rainy/Cloudy/Foggy) : Heavy rain Whether Collision with :

Speed of The Vehicle:_20 km______ Traffic Density (Peak time/ Non peak) : Non Peak

Details of accident : accident Due to rain. My Bike was slipped and I Losses the Balance and fell into the Nallaha

DESCRIPTION OF INJURY (Brief description; medical or other services provided including expected days lost.) There is Minor ankle Injury my ankle got twist

Likely Date of Resuming duty: 23 /08/11 Whether accident has been reported / recorded with Police (or any other authority) No

_Amardeep Singh_______________ _______________________ Signature of person reporting

Signature of Verifying person : RBM / AM or Admin. Manager HO