Page 60 - On Call folder
P. 60

SF001
                                           Accident Investigation Form                                  Issue 1
                                                                                                     03/09/2012


              Reported to AIRline?    Yes       No           Reported to Client?       Yes       No
              AIRline Tel No:   01473 242354                 Clients Name:

              AIRline Mobile:   07900 265850 - for use outside office hours   Clients Tel No:

              Name of Person Completing the Form:

              Job Title:                             Location:

              Telephone:                             Organisation Name:

              Employer:                              Project Manager / Director:

              Reported by:                           Date:


             1. General

              Date of Occurrence:                                                  Time:                                  hrs

              Occurrence Location:

              On Network Rail Controlled Infrastructure?   Yes     No

              Red Zone or Green Zone?             Possession No:         Type of Protection/Possession:

             2. Personal Details

                                                      Contractor / Other  (Please
              Person Type:                                   specify company)

             Name of Injured Person:   Surname                                       Male        Female

                                   Forename(s)

              Date of Birth:                                National Insurance Number:

              Date Entered Service:                        Date Entered Present Grade:

              Date / Time Turn Started on Day of Accident/ incident?           /             /   at                                  hrs

              Date / Time Previous Turn Finished?                /             /   at                                  hrs

              No. of Shifts Worked Since last Day off ?

             3. Injury

              Was Person
                               Yes         No       (if no please state nature of incident):
              Injured?

              Treatment on Site By:   Name (if known)

                 None administered              Member of Staff         Self Administered
              Ambulance / Paramedic                   Nurse             Trained First Aider
                         Doctor          Other Emergency Service           Other Person

              Was the Person Taken to Hospital?   Yes     No

              Were They Taken Immediately?   Yes        No         Name of Hospital:

              Were They Detained for More Than 24hrs?   Yes     No

              Days Lost:*    NIL         1 Day          2 Days          3 Days          3+ Days

              * Please inform the S&Q and the Personnel departments when employee has returned to work

              Degree of Injury:   Fatal        Major          Minor        No Physical Injury


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