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:
Line Category:
Other Obstruction:
 
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:
PART D
Injury
Injury Type:
[choose]
Injury Site:
[choose]
Event Type:
[choose]
 
PART E
Accident 
Train Accident:
[choose]
Failure:
[choose]
Accidents to passengers involving trains:
[choose]
Other accidents to passengers:
[choose]
Accident to railway employees and contractors involving moving trains:
[choose]
Other accidents to railway employees and contractors:
[choose]
 
Trains
Reporting Number:
Place of Origin:
Destination:
Speed:
Train Type:
 
Delays
Affected Lines:
 
Description
Details: