Dit Incident Report Form
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1DIT INCIDENT REPORT FORM
All incidents resulting in personal injury, damage to property, dangerous occurrences, or near misses,
must be reported within 24 hours by completing this form.
086 389 1080
In the case of a serious incident the DIT Health & Safety Officer can be contacted on
Or 4024192.
ALL sections are to be completed and signatures obtained and when complete, please send to:
Health & Safety Office, DIT, 40-45 Mountjoy Square, Dublin 1
1. General Information
Date of incident: _______________________________
Time of incident:____________________________________________
Exact location of incident:
(give building & room number)
__________________________________________________________________________________________________________
2. Details of Injured Person (where applicable)
Name: ___________________________________________
Sex (M/F):___________ Date of Birth: _______________________
Address: ____________________________________________________________________________________________________
Contact No: _________________________________
Nationality: IRISH
EU
NON EU
Staff
Post Grad. Student
Student/ Apprentice
Visitor
Contractor
Other
____________________
DIT Department / Course: _______________________________________________________________________________________
Reason for being in location: ____________________________________________________________________________________
3. Incident Details
When was incident first reported? ________________________________________________________________________________
To whom was it reported to?
(name & job title)
_________________________________________________________________
Did the injured person cease work immediately? (Y/N)__________ If no, when did work cease? _____________________________
Description of injury / incident (including preceding events):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Task being done at the time of incident: ____________________________________________________________________________
Details of tools/machinery/ PPE or equipment required to perform the task: _______________________________________________
Were they being used? (Y/N)______ If so, please specify the type & condition: ____________________________________________
4. Injury / Illness Details
Describe HOW the person was injured: ____________________________________________________________________________
What type of injury was sustained? _______________________________________________________________________________
(e.g. cut, burn, sprain/strain)
What part(s) of body were injured (specify left or right side)?___________________________________________________________
What first aid was given? _______________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
First Aider: ______________________________________________________________ Contact No._________________________
(name & job title)
Returned to work
Sent to DIT Health Centre
Sent to Hospital by Ambulance
Sent to Hospital by Taxi
Sent to GP
Sent home
Other ____________________________________________________________________
Witness to incident:
(name & job title)
_____________________________________
Contact No.____________________________
5. Corrective Action / Prevention
(What action has/will be taken to prevent further incidents occurring)
Short term plan:___________________________________________________ Person Responsible:__________________________
Long term plan:____________________________________________________ Person Responsible:__________________________
6.
Signature of Person Completing Form:________________________________________ Date:____________________
Date Received by Health & Safety Office: _____________________________ Reference No.________________________________
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