Page 55 - On Call folder
P. 55

SF001
                                           Accident Investigation Form                                  Issue 1
                                                                                                     03/09/2012


             12. Description of Accident/ Incident  (continue on separate sheet if necessary)






















              13. Line Manager / Supervisor Comments & Remedial (Short Term & Long Term) Actions

              (Continue on separate sheet if needed)






















              14. Injured / Involved Persons Comments as to How Accident/ Incident Could Have Been Prevented

              (Continue on separate sheet if necessary)


















             15. Actions

              What positive         Briefing on correct tools      No appropriate action      Staff disciplined / briefed
              actions have             Hazard eliminated      Safe system of work introduced      Training required
              been taken to
              prevent             Hazard repaired / replaced      Safe system of work modified      Other (specify below)
              reoccurrence?    Maintenance procedures reviewed       Staff counselled


                                                                                                          Page 1 of 6
            Please send all completed forms back to PHoSS                                            Page 4 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 4 of 6
           Uncontrolled copy once printed from its electronic source
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