Page 59 - On Call folder

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