NOTIFICATION OF OCCURRENCES FORM AND NOTES FOR COMPLETING RAIL SAFETY UNIT Railway Code Incident No. Year NOTIFICATION OF OCCURRENCE (in accordance with Section 74, Rail Safety Act 2007) Reporting Railway Organisation Other Affected Railway Organisation Location of Occurrence Date of Occurrence Day, Month, Year Time of Occurrence (24 Hour Clock)     Description of Occurrence: Cause: Alcohol / Drug Test called for? Yes: No: Result: Positive: Negative: -- If positive, provide details Consequences   Person Property Fatality Serious Injury Minor Injury Given / Surname Age Sex Address Damage $ Passenger Public Employee Contractor Volunteer Trespasser Details of reporting person: Name Position email Phone. No Business Address Postcode: Date 12 October, 2000 TSA Form No. TUM-RS-01 Notes for completing the Notification of Occurrences Form Each occurrence must be on a separate form (unless other specific arrangements have been made with Transport SA ). If insufficient space, attach additional page(s) Railway Code A specific code issued by Transport SA for your organisation. Incident No. Consecutive number inserted by your organisation commencing at 0001 for each calendar year. Year Final two digits of the current calendar year. Reporting Railway Organisation Enter name of accredited railway reporting occurrence. Other Affected Railway If applicable enter name of any other railway involved. For example, if you are the Organisation operator of a train using another railway's track, enter the name of the track owner. Location, Date and Time of Occurrence Each box must be completed. Description of Occurrence: Railways need to ensure that adequate information is provided to clearly describe the occurrence. The description should include, but is not limited to, the following information: type of occurrence how the occurrence happened persons alcohol / drug tested and result the rolling stock involved (include type(s) and fleet number(s)) the personnel involved the train or trains involved (include type, eg. passenger, freight, other) section of track involved brief description and nature of damage [If there is insufficient space, attach additional page(s)] Cause To be entered if known at the time the report is completed. For example, the cause of a derailment may have been a broken rail. Cause of fatality or injury may be suspected suicide. Passenger A person who is joining, on, or alighting from a train (for the purpose of travelling) not necessarily in possession of a ticket or authority to travel, and includes an employee, contractor or volunteer not travelling in the course of their duties. Injuries Classes refer to the following: Serious Admission to Hospital Minor NOT Admitted to Hospital Property Damage $ Preliminary or indicative estimates are acceptable for this report. Enter $ value. A guide to property damage severity may be extracted from this table below. Low $1 - $10,000 Moderate $10,001 - $100,000 High $100,001 - $1,000,000 Extreme $1,000,001 plus FORWARD COMPLETED FORMS within 72 hours of occurrence happening to: Rail Operations & Safety Section Transport SA By Email: rail@transport.sa.gov.au By Fax : (08) 8343 2718 By Mail :      (Please mark RAIL SAFETY) P.O. Box 1 Walkerville 5081 By hand :     (Please mark RAIL SAFETY) Reception 4th Floor 33 - 37 Warwick St. Walkerville 5081