Form 17A – Notice of Dangerous Occurrence (Not Resulting in Death or Bodily Injury)

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Form 17A is a statutory notification form used to report dangerous occurrences, hazardous incidents, or near-miss events that do not result in death or bodily injury. The form enables employers to document and report potentially serious workplace incidents for investigation, corrective action, and regulatory compliance.

By Labour Department / Chief Inspector of Factories / Occupational Safety & Health Authority · Published 2026-11-02 · Updated 2026-11-02

From the document

FORM 17 A (Prescribed under rule 106) Notice of dangerous occurrence, which does not result in death or bodily injury (Vide Para 2 of schedule under rule 106) 1. Name and address of the factory __ 2. Name of the occupier __ 3. Name of the manager __ 4. Nature of industry __ 5. Branch or Department and exact place __ where the dangerous occurrences took place 6. Date and hour of occurrence __ 7. Nature of dangerous occurrence __ (State exactly what happened) I certify that to the best of my knowledge and belief, the above particulars are correct in every respect. Signature of the Occupier/Manager Date of dispatch of report Note: to be completed in legible handwriting/preferably typewritten (This space is to be completed by Inspector of Factories) District: Date of Receipt: D.O. No.: Date of Investigation: Causation No.: Result of Investigation:

form 17a · notice of dangerous occurrence · dangerous occurrence report · near miss report · safety incident report · hazardous occurrence · industrial incident · workplace incident · factory safety · occupational safety

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