TDD Dangerous Occurrences,Incidents or Near Misses Report

• Site involved

  Select

• Doc. No.

• Report raised by

  Sign
• Add location
  Address

• Reportee - Personnel/Patient/Public

  GC Employee

  Non GC Employee - Clinical

  Patient

  Contractor

  Outside Agency -(e.g. Police)

• Dept.?

Occurrences or Near Misses report

• Location
  Address

• Incident date (dd/mm/yyyy)

  Date

• Time incident occurred

  Date

• Name of Persons Involved Surname , First Name

Persons Involved (click as many as applicable)

• Persons Involved (click as many as applicable)

  Select GC Employee Non GC Employee - Clinical Patient Contractor Outside Agency -(e.g. Police)

  • GC Employee
  • Non GC Employee - Clinical
  • Patient
  • Contractor
  • Outside Agency -(e.g. Police)

• Dept.?

• Other

If Outside agencies/other, please state person(s) and reason for presence

• undefined

Environmental Conditions

• Conditions at the time of the incident

  Select Inside Outside Good Light Poor Light Wet Snow/Ice Dry Level Slope

  • Inside
  • Outside
  • Good Light
  • Poor Light
  • Wet
  • Snow/Ice
  • Dry
  • Level
  • Slope

Incident classification - what happened? Click as many as applicable

• No injury - near miss

  Yes

  No

  N/A

• Type of Injury

  Select Strain/Sprain Bruising/Swelling Minor Lacerations Minor Scalds/Burns Bite/Sting Severe Scalds/Burns Foreign body in eye Major Lacerations incl. stab wound Crush/Fractures Amputations Major Orthopaedic - Multiple limb Coronary/Stroke Psychological Violence and Aggression - Verbal Abuse Violence and Aggression - Verbal Assault Violence and Aggression - Battery Substance Abuse/Exposure - Asbestos Substance Abuse/Exposure - Biological/Chemical/Radiation Substance Abuse/Exposure - Other Spinal/Brain Death

  • Strain/Sprain
  • Bruising/Swelling
  • Minor Lacerations
  • Minor Scalds/Burns
  • Bite/Sting
  • Severe Scalds/Burns
  • Foreign body in eye
  • Major Lacerations incl. stab wound
  • Crush/Fractures
  • Amputations
  • Major Orthopaedic - Multiple limb
  • Coronary/Stroke
  • Psychological
  • Violence and Aggression - Verbal Abuse
  • Violence and Aggression - Verbal Assault
  • Violence and Aggression - Battery
  • Substance Abuse/Exposure - Asbestos
  • Substance Abuse/Exposure - Biological/Chemical/Radiation
  • Substance Abuse/Exposure - Other
  • Spinal/Brain
  • Death

• Other

Incident Hazard type - Occurred as a result/in relation to -

• undefined

  Select Slip/Trip Ergonomics/handling Fire Electrical At Height Struck by moving object Construction Driving Equipment/Mechanical Lone Working Confined Space Water/liquid related Environmental - Poor Light/wet/Noise/Radiation Animal/Insect Natural Causes / not directly task related

  • Slip/Trip
  • Ergonomics/handling
  • Fire
  • Electrical
  • At Height
  • Struck by moving object
  • Construction
  • Driving
  • Equipment/Mechanical
  • Lone Working
  • Confined Space
  • Water/liquid related
  • Environmental - Poor Light/wet/Noise/Radiation
  • Animal/Insect
  • Natural Causes / not directly task related

Outcome

• Was it RIDDOR reportable?

  Yes

  No

  N/A

• HSE Form 2508 Type?

  Select YES - Injury Yes - G1 Flammable Gas Incident Yes - G2 Dangerous Gas Fitting Yes - Dangerous Occurence

  • YES - Injury
  • Yes - G1 Flammable Gas Incident
  • Yes - G2 Dangerous Gas Fitting
  • Yes - Dangerous Occurence

Harm received

• Was there a physical injury?

  Yes

  No

  N/A

• Affected parts - Click as many as applicable

  Select Head Ears Left Eye Right Eye Back - Shoulders Left Arm Left Hand Right Arm Right Hand Back - Lower Chest Abdomen Groin Buttocks Right Leg Right Foot Left Leg Left Foot Internal organs

  • Head
  • Ears
  • Left Eye
  • Right Eye
  • Back - Shoulders
  • Left Arm
  • Left Hand
  • Right Arm
  • Right Hand
  • Back - Lower
  • Chest
  • Abdomen
  • Groin
  • Buttocks
  • Right Leg
  • Right Foot
  • Left Leg
  • Left Foot
  • Internal organs

• Please provide full details of what happened (please use people's initials instead of full names) Send any photo's under separate cover.

• undefined

• Please describe remedial actions to make safe/recurrence ( please use people's initials instead of full names)

• undefined

Thank you for completing the report, please print a copy for your own records. The Quality Team.