Title Page
-
Site conducted
-
Full Address of Site
-
Owner
-
Owner Contact number
-
Date Incident Report Carried out
-
Prepared by
-
Type of Incident
Section B - Injured Party Details
-
Injured Party
- Employee
- Contractor
- Haulier
- Other
-
If other please specify
-
Name
-
Contract Number
-
Address
-
Location of Incident onsite
-
Date and time of incident
Section C - Description of Incident - Brief details of the Incident, facts only Describe: A) How the Incident occurred; B) The Injury Sustained (be specific, e.g. cut, thumb, right hand);
-
Enter details to above here
Section D - Photograph of Incident
-
Please take photographs of incident location:
-
Name of person who took photo:
-
Date and time photo was taken
E. Response to Incident
-
Nature of Treatment administered:
-
First Aid administered:
-
First Aid administered by:
-
Ambulance called
-
Name OR ID Number of Ambulance Crew:
-
Gardaí called:
-
Name OR ID Number of Gardaí :
-
Closed Circuit Television (CCTV) footage copied (from 24hrs before & after incident):
Section F - Witness Statements - Take a statement from each witness, record on separate sheet, sign & attach to Report
-
Were there witness to the incident?
-
Name:
-
Address:
-
Phone number
-
Name:
-
Address:
-
Phone number
-
Name
-
Address
-
Phone number
Section G - Report Sign-Off
-
Report Completed by (Print name):
-
HSA / EPA Reportable:
-
Position:
-
Signature:
-
Date and Time
Items to accompany this Report
-
Photographs, Witness Statements, and CCTV Footage
