Accident Or Dangerous Occurrence

PART A

Contact

Title:

[choose]

Firstname:

Surname:

Job Title:

Telephone:

Email:

Company

Postcode: **

If you don't live in Northern Ireland, or you can't find your address,enter your address below.

Name:

Property:

Street:

Locality:

Town:

County:

Email:

What type of work does your organisation do?:

PART B

Incident

Date of Incident:

Time of Incident:

Incident Location:

[choose]

PROMPT:

If at the above address please state ‘As above’, otherwise provide full address including post code

Address/Location Details:

Local Authority:

[choose]

Department / Location where incident occurred:

PART C

Injured Person

Title:

[choose]

Firstname:

Surname:

Postcode: *

If you don't live in Northern Ireland, or you can't find your address,enter your address below.

Property:

Street:

Locality:

Town:

County:

Phone:

Age:

Gender:

Female

Male

Job Title:

[choose]

Status:

[choose]

If ‘Other’ or ‘Employed by somebody else’,specify details:

PART D

Injury

Injury Type:

[choose]

Injury Site:

[choose]

Event Type:

[choose]

Become unconscious?:

Yes

Need Resuscitation?:

Yes

Remain in hospital for more than 24 hours?:

Yes

PART E

Accident

Kind of Accident:

[choose]

PART G

Describing what happened

Give as much details as you can. For instance :

the name of any substances involved
the name and type of any machine involved
the events that led to the incident
the part played by any people

If it was personal injury, give details of what the person was doing.

Describe any action that has since been taken to prevent similar incident.

Description: