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Note:the fields that are marked in green are mandatory
Case Type
Incident Details
Date Of Incident
Time
Port/Location
Vessel/Site
Detailed Location
Shipping Line
Master/Supervisor at time of incident
Operating Office
Reported By
Name Of Company, if 3rd party
Incident Description
Equipment involved
Equipment number
immediate action taken
weather condition
road condition
visibility
suggestion for improvement
Involved Person/Witness details(if any)
Employment Category
first Name
Surname
Person Involved as
Telephone Number
Job Title
Social Security Number
Home/work Address
If Over the road driver, drivers license no.
Injured persons details
Employee number
National ID

Incident
Pickup 08 hit a concrete barrier 08J
training area
7/17/2014
1:00 PM
Port Said
Yard

OPS
OPS

Pickup 08 hit a concrete barrier 08J

training area
8.Pick up
8

Clear
Dry
Good

First Name
Surname
Home address

Phone
TWIC No./ID No.
Work address
Social Security Number
Date Of Birth
Gender
age
Employment category
company
Unit/Department
3rd party type
job title
marital status

Actual event type

A.]Occupational health details[caused by working
conditions]
(if any)
Severity of illness
Type of illness
Estimated workdays lost
Actual workdays lost
Estimated workdays restricted
Actual workdays restricted
B.]Safety details[caused by working conditions]
any)
Accident category

Enter The details

(If

Course of events
Type of injury
Part of body harmed
Estimated workdays lost
Actual workdays lost
Estimated workdays restricted
Actual workdays restricted
Indicate location of medical treatment
Was PPE or safety equipment in place
C.]Fire/explosion details(If any)
Fire type
Ignition sources
Primary exinguishing System
volume used
Description

Fire Type 1

D.]Asset damaged details(If any)

Property/Equipment Type
Property/Equipment
Is
The container able number
to move out via
vessel/rail/chassis
Does The container need M&R to take action
Department

Asset damaged 1

Explain Damage
Damage caused by
Pre-existing damage
Forpre-existing damage,(if cargo/container) eter the
ship name/gate number/date/cargo type.
Must track repair expenses.

Operating office in charge of case

Person in charge

Fire Type 2

Fire Type 3

Asset damaged 2

Asset damaged 3

Contractor
Customer
Employee
Full-time employee
Government Authorities
Hired
Others(Please Specify)
Over the road/external driver
Port employee
Shipping Line/Vessel crew
Substitute
Vendor
Visitor
Involved
Witness

Clear
Fog
Ice/Snow
NA
Overcast
Rain
Sun
Thunder storm
Windy

CHE
1.Chassis/Trailer
2.Empty Handler
3.Mobile Crane
4.Rail-Mounted Gantry(RMG)
5.Reach Stacker
6.Rubber-Tired Gantry(RTG)
7.Ship Crane
8.Ship-To-Shore-Crane
9.Shuttle Carrier
10.Straddle Carrier
11.Terminal Tractor
12.Top Loader
CONTAINER
1.Dry
2.Flat rack
3.Open Top

4.Reefer
5.Tank
MISCELLANEOUS
1.Building/Facility
2.Cargo
3.Chassis Flipper
4.Lashing Gear
5.Leakage Trailer
6.Others(please specify)
7.Over Height Frame
8.Rail Chassis
9.Safety/Lashing Cage
10.Spreader
11.Tug/Boat
12.Vessel
VEHICLE
1.3rd party vehicle
2.Bus
3.Car
4.Emergency Vehicle
5.Fork Lift
6.Fuel Truck
7.Man Lift
8.Pick up
9.Sweeper.

No
Yes
Undetermined
Cargo
Chassis
Container
No
Yes
Observation
Near Miss
Incident

Building
Dock/Quay
Gate
Inspection Area/CFS
Off-Site
Other(Please Specify)
Parking
Rail
Vessel
Warehouse
Workshop(M&R)
Yard

Dry
Flooded
Ice/Snow
Muddy
NA
Oil/Grease
Sandy
Uneven
wet

AOM/Shift Manager/Ops
Clerk/Checker
Driver:3rd Party
Driver: Company Vehicle(Bus,Car,Pickup,Motorbike)
Driver: Container Handling Equipment
Driver: Forklift
Driver:UTR/Terminal Tractor
Flagman/Signalman/Wharf Controller
Foreman/Supervisor
Gearman/Lasher(Vessel)
Line Handler/Mooring Crew
MESC
Mechanic/Engineer/Technician
OCU
Others-3rd party(please specify)
Others-Employees(please specify)
Pinman/Coneman/Lasher(Quayside)

APL
CMA CGM
COSCO
CSAV
China Shipping(CSCL)
Eimskip
Evergreen Marine Corp
Hamburg Sud
Hanjin
Hapag Lloyd
Horizon Lines
Hyundai(HMM)
Item2
K-Line
MSC
Maersk
Mol_group
NYK
OOCL
Others(Pl Specify)
PIL
Shandong
UASC
Wanhai
Yang Ming
ZIM

Allergic reaction
Asbestosis
Cancer
Cardio logical
Contagious Disease
Cumulative trauma
Diseases caused by biological agents
Diseases caused by chemical agents
Diseases caused by physical agents
Hearing loss
Heat Prostration/Heat stroke
Mental stress
Non Occupational
Not selected
1.Poisoning
2.Radiation

Security
White Collar

3.Respiratory
4.Silicosis

Abdomen/stomach
Ankle
Back/spine
Buttock/hip/groin
Chest
Ear
Elbow
Ear
Eye
Face/head
Hand/wrist
Knee
Left arm
Left foot
Leg
Lower arm
Mental/emotional
Neck
Nose
Right arm
Right foot
Shoulder
Skull
Throat
Thumb
Toe/nail
Upper arm
Whole body
Finger
Forehead
Others (please specify)

Abrasion/Bruise/Contusion
Amutation
Burn
Burn/Scald
Cardiac/respiratory
Concussion
Contusion/Bruising/contact skin
Crushing
Cut/Open wound
Cut/Laceration/scratched/punctured
Damage caused by electricity
Dislocation
Electric shock
Emotional Stress
Exposure
Fatal
Foreign body in wound
Foreign object Invasion
Facture
Fracture/sprain
Hernia
Illness
Injury to internal organ
Internal ache/pain
Jostling
Multiple injuries
Muscle Strain
Pass-out
Poisoning
Reaction to Chemical
Skin Irritation
Smash/Trauma
Soft Tissue Injury
Sprain
Stress
Superficial Injury
Swelling
Traumatic Amputation
Twist/Bend
Unknown

Good
NA
Poor
Satisfactory
Very good
Very Poor

Man
Woman

divorced
domestic partner
living together
married
registered partners
separated
single
unknown
widowed
Contractor
Customer
Government Authorities
Others(Please Specify)
Over the road/external driver
Port employee
Shipping Line/Vessel crew
Vendor
Multiple fatalities
single fatality
LTI
Days away from work
Restricted work
Medical treatment only
first aid only
incident only
yes
no

Other type of fire

Electrical fire
Fire in solid materials
Fluid fire
Hydrocarbon fire
Metal Fire

others(Please Specify)
Auto Sprinkler dry pipe
Auto Sprinkler-wet pipe
Dry Chemicals
Fire water monitors
Fire Truck
Foam system
Halon Release
Hand extinguisher
Overpressure/ventilation fans
Permanent CO2 system
Shutdown
Smoke and Fire doors
Water
Water mist
Water spray-AFFF
water wall
Others(Please Specify)
3rd party
Terminal

-EUR
-Inland Services
Addicks & Kreye - Bremerhaven
APMT Romania - Constantza
Dania Trucking - Aarhus
Maersk Denizcilik- Kemalpasa - Izmir
Neuss Intermodal Terminal - Neuss
Pentalver Cannock - Cannock Rumer Hill
Pentalver Transport - Southampton109 Site
Pentalver Transport - Felixstowe Blofield Road
Pentalver Transport - Felixstowe Nicholas Road
Pentalver Transport - Ipswich West Bank Terminal
Pentalver Transport - Southampton Dock Gate 10
Pentalver Transport - Southampton Dock Gate 20
Pentalver Transport - Southampton Rail Terminal
Pentalver Transport -Tilbury 34 Berth
REMESA - Algeciras
Star Container - Algeciras
Star Container - Bremerhaven
Star Container -Fos sur Mer
Star Container - Hamburg
Star Container - Le Havre
Star Container services - Antwerp
Star Container Services - Maasvlakte
Star Container Services - Rotterdam
Star Container Services - Zeebrugge
Star Container - Tunis-Rades
Star Transportation - Bremerhaven
Star Transportation - Hamburg
-Terminals
Aarhus
Algeciras
Bremerhaven
Dunkirk
Port Said
Regional Office(EUR)
Rotterdam
Tangier
Zeebrugge

Multiple fatalties
single fatality
LTI
Days away from work
Restricted Work
Medical Treatment only
First aid only

ADM/MGT
COM/MKTG
ENG/TECH
FIN
HR
HSE
IT
OPS
SECURITY