PART A
Contact
Title:
[choose]
Firstname:
Surname:
Job Title:
Telephone:
Email:
 
Company
 
Name:  
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:
 
Business:
[choose]
Other:
Your Reference:
PART B
Incident
Date of Incident:
Location:
Grid Reference:
Dangerous Occ. No.:























For further guidance on dangerous occurrences which are reportable in relation to railways, please see: http://www.legislation.gov.uk/nisr/2004/196/regulation/2/made
 
PART C
Injured Party
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:
Age:
Gender:
Status:
[choose]
If ‘Other’, specify details:
Injury
Injury Type:
[choose]
Injury Site:
[choose]
Event Type:
[choose]
 
PART D
Level Crossing
Protected Level Crossing:
[choose]
UnProtected Level Crossing:
[choose]
Was the Level Crossing?:
Number of Tracks:
Permitted Train Speed:
Pre-existing Faults?:
PROMPT:
If Yes, please give full details in PART F
Supervising signal box?:
Yes – what is it’s name:
Operated by the train crew?:
User-worked?:
Crossing user-worked?:
How is warning of trains given:
Sighting Distance (all crossings)
From an up train (m):
From an down train (m):
Sighting Distance (unprotected crossings) 2 meters from nearest rail
On the up train side:
On the down train side:
Gate/Barrier
Normal Barrier Position:
Gates interlocked with protecting signal?:
Wicket Gates?:
Wicket Gate Lockable?:
Locked at time of accident?:
PART E
Trains Involved
Reporting Number:
Time and place of origin:
Place of destination:
Speed:
mph
Type of train:
Line Category:
PART F
Accident Description
Details: