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:
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:
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?:
Need Resuscitiation?:
Remain in hospital for more than 24 hours?:
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: