Title Page
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Site conducted
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Conducted on
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Report raised by
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Add location
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Reportee - Personnel/Patient/Public
Report Detail
Occurrences or Near Misses report
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Location
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Incident date (dd/mm/yyyy)
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Time incident occurred
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Persons Involved Surname , First Name
Persons Involved (click as many as applicable)
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Persons Involved (click as many as applicable)
- GC Employee
- Non GC Employee - Clinical
- Patient
- Contractor
- Outside Agency -(e.g. Police)
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Other
If Outside agencies/other, please state person(s) and reason for presence
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Environmental Conditions
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Conditions at the time of the incident
- Inside
- Outside
- Good Light
- Poor Light
- Wet
- Snow/Ice
- Dry
- Level
- Slope
Incident classification - what happened? Click as many as applicable
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No injury - near miss
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Type of Injury
- 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
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Other
Incident Hazard type - Occurred as a result/in relation to -
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- 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
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Was it RIDDOR reportable?
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HSE Form 2508 Type?
- YES - Injury
- Yes - G1 Flammable Gas Incident
- Yes - G2 Dangerous Gas Fitting
- Yes - Dangerous Occurence
Harm received
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Was there a physical injury?
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Affected parts - Click as many as applicable
- 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
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Please provide full details of what happened (please use people's initials instead of full names)
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Please describe remedial actions to make safe/recurrence ( please use people's initials instead of full names)
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