Incident South Clean (29) – Remote Services

Incident Report - South Clean

SOUTH CLEAN

INCIDENT REPORT FORM

Private and Confidential

Tick which Applies

Accident = An unplanned, unwanted event that results in injury, ill health or damage to plant or equipment or some other loss.
Near Miss = An unplanned, unwanted event that had the potential to cause injury, ill health or damage to plant or equipment or some other loss but did not do so.
Dangerous Occurrence = An incident with a high potential to cause death or serious injury

Accident

Near Miss

Dangerous Occurrence

Personal Details of Injured party

Name of Injured Party

Date of Birth

For speed, click into the year, type the year, then use arrows to select month

Job Title (or indicate if the person is a member of the public)

Address

Address Line 1

Address Line 2

Town

County

Eircode

Country

Phone

Does the Injured Party allow their personal details to be disclosed?

Yes

Details of any Machinery, Tools, Plant or Equipment Involved

Description of Machinery

Make/Model/Serial/Registration No.

Details of Defect/Damage

The Accident

When did the Accident Occur?

Date of Accident

Time of Accident

Address of where the accident occurred

Address Line 1

Address Line 2

Town

County

Eircode

Exact location of accident

Describe what happened

Any Photos of the Accident? Please attach at the end of this form

Details of the injury

Please give details of the injury

Corrective Action

What corrective action was taken? Was any First Aid administered on the premises? If yes, what treatment did they receive and who administered it? Did they go to hospital?

Witness Details

Witness Details

Name	Contact Number	Address

Do the witnesses allow their personal details to be disclosed?

Yes

HSA Reportable Injuries

Do you need to report an injury to the HSA?

See here

Is the accident reportable to the HSA?

Yes

Has the accident been reported to the HSA?

Yes

People Involved in Incident

Name and Address of Site and Location within Site

Activity being Undertaken

Date of Incident

Time of Incident

Description of Incident

Equipment Involved

Any Photos of the Incident? Please attach at end of form

Any other Information Relevant?

Person completing the form

First Name

Last Name

Job Title

Signature

Sign Here

Date

Attach your documents

SOUTH CLEAN

INCIDENT REPORT FORM

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