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SF001
                                           Accident Investigation Form                                  Issue 1
                                                                                                     03/09/2012


              OFFICE USE ONLY



              Is there an accident or incident book   Yes      No      Has the Safety Rep been   Yes       No

              entry?                                               advised?

              Accident or Incident Classification (See SP02 for definitions)

              Actual Category:    1 Near Miss      2 Damage Only      3 Minor Injury      4 Medical Treatment

                 5 Restricted Work Condition      6 Lost Time Accident     7 Over 3 Day     8 Major Injury

                   9 Dangerous Occurrence         10 Fatality     11 Disease

              Potential Category:

              Estimated Frequency of Recurrence:    Frequent      Occasional      Improbable

              Full Investigation Required:       Yes              No

              Investigation Manager Name:                                   Notified   Yes      No

              Accident/ Incident Reported to Enforcing Bodies?    Yes       No       Ref No:

              Date Accident/Incident Reported to Client            To whom?

              Works Type:   Renewals       Maintenance        Other         State What:


              PHoSS Comments






















              Signed:                                          Signed:

              Print Name:                                      Print Name:
               (Line Manager/Supervisor)                       Professional Head of Safety & Standards
              Date:                                            Date:


                                                                                                          Page 1 of 6
            Please send all completed forms back to PHoSS                                            Page 6 of 6
           S:\Resource Management\On-Call\On-Call  Folder 5.6.18\9. AccidentIncident Near Miss Reporting & Investigation\SF001 Accident Investigation Form Issue No 01 03-09-2012.docP      Page 6 of 6
           Uncontrolled copy once printed from its electronic source
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