Page 52 - On Call folder

SF001
Accident Investigation Form Issue 1
03/09/2012

4. Nature of Injury

Part(s) of Body Affected? Body Side? Left
Right

Amputation Crush Injury Fracture Multiple Injuries
Bite / Sting Cut / Laceration Inhalation / Ingestion Puncture Wound
Bruise / Abrasion Dislocation Internal Injury Shock
Burn / Scald Electric Shock Loss of Consciousness Strain / Sprain
Concussion Foreign Body in Eye Loss of Sight Whiplash
Other (State what)

5. Site

Bridge/Viaduct/Arch Office Signal box Track or Line-side Workshop
Depot On Board Train Station Tunnel Yard
Level Crossing Public Highway Other State where

Was the Site
Yes No Indoors or Outdoors
Inspected?

Lighting Bright Sunlight Daylight Floodlight Headlamp / Torch
Dawn / Dusk / Twilight Electric Bulb Fluorescent Tunnel Lights
Darkness (no artificial light) Other State what

Weather Bright Sunlight Falling Rain Frost Lightning / Storm
Dull / Overcast Falling Snow High Wind Mist
Fair / Fine Freezing Indoor / Under Cover Thick Fog
Other State what

6. Workforce

Occupation Depot / Yard Staff Office Staff Trackside Staff Workshop Staff
Other State what

Based at: (Home Depot / Office)

Safety Critical Worker: Yes No Normal Activity: Yes No

Duties: Emergency Call Out Ordinary Overtime Rest Day Worked Sunday
Other State what

Level of Supervision: Working with others supervised Working under direct supervision Working alone
Working with others unsupervised Supervising others

Substance Abuse Test: Blood Breath Urine Not Tested

Result (if tested): Medical Limitations: Yes No

7. Activity

Underfoot Surface Conditions
Ballast Concrete Earth Lino Paving Tiles
Brick / Paving Blocks Carpet Gravel Metal Tarmac Wood
Other State

Page 1 of 6
Please send all completed forms back to PHoSS Page 2 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 2 of 6
Uncontrolled copy once printed from its electronic source