Page 55 - On Call folder
P. 55

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
   50   51   52   53   54   55   56   57   58   59   60