The Health and Safety Incident Report Form is a crucial document required under Irish health and safety legislation, specifically the Safety, Health and Welfare at Work Act 2005 and associated regulations. This form must be used to record any workplace incident, accident, or dangerous occurrence that results in injury, property damage, or presents a significant risk. It captures essential information including incident details, affected persons, witness accounts, immediate actions taken, and follow-up measures. The document serves multiple purposes: ensuring compliance with HSA reporting requirements, maintaining accurate incident records, facilitating incident investigation, identifying preventive measures, and supporting potential insurance or legal proceedings. Organizations must ensure this form is readily available and that relevant staff are trained in its proper completion and submission.
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1. Report Information: Basic administrative details including report date, reference number, and person completing the form
2. Incident Details: Date, time, location, and type of incident
3. Affected Person(s) Information: Personal details of injured/affected person(s) including name, role, contact information
4. Incident Description: Detailed account of what happened, including sequence of events and immediate actions taken
5. Witness Information: Names and contact details of any witnesses to the incident
6. Injury/Damage Details: Nature and extent of any injuries or damage to property
7. Initial Response: First aid or immediate actions taken, including emergency services involvement
8. Risk Assessment: Evaluation of the hazards involved and existing control measures
9. Investigation Findings: Root cause analysis and contributing factors
10. Corrective Actions: Measures taken or planned to prevent recurrence
11. Sign-off: Signatures of relevant parties (reporter, supervisor, safety officer)
1. Environmental Impact: For incidents involving environmental releases or damage
2. Equipment/Machinery Involved: Detailed section for incidents involving equipment or machinery failure
3. Contractor Details: For incidents involving contracted workers or services
4. Medical Report: Detailed medical information for serious injuries requiring professional treatment
5. Cost Impact: Financial implications of the incident including property damage, lost time, etc.
6. Training Records Review: Review of relevant training records when lack of training may be a factor
7. HSA Notification Details: For incidents requiring mandatory reporting to the Health and Safety Authority
1. Appendix A - Incident Classification Guide: Guidelines for classifying the severity and type of incident
2. Appendix B - Body Map: Diagram for marking location of injuries
3. Appendix C - Photo Log: Template for documenting photographic evidence
4. Appendix D - Witness Statement Form: Standard format for collecting detailed witness accounts
5. Appendix E - Risk Matrix: Tool for assessing the risk level of the incident and potential future risks
6. Appendix F - Investigation Checklist: Structured checklist for ensuring thorough incident investigation
7. Appendix G - Relevant Emergency Contact Numbers: List of emergency contacts and reporting authorities
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