HC NIRF 01 – V10
Date issued: 03/05/2018
NATIONAL INCIDENT REPORT FORM (NIRF)
NIRF - 01 PERSON
Incident: An event or circumstance which could have, or did lead to unintended and / or unnecessary harm. Please complete this form to the best of your knowledge at the time of reporting the incident.
SECTION A: GENERAL INCIDENT DETAILS
g. Hospital, Health Centre, Residential Centre etc.
SECTION B: PERSON AFFECTED DETAILS
____________________________
____________________________
Division (tick one only )
Acute Hospital
Social Care
Health and Wellbeing
Primary Care
Mental Health
Ambulance Service
National Corporate Services (staff only)
Who was involved…? (tick one only )
Service user – (Resident/Patient/Client) Go to section C
Staff member – Go to section D
Agency / Panel staff – Go to section D
Member of public – Proceed to section F
Volunteer – Go to section D
External Contractor – Go to section E
Student – Go to section D
SECTION C: SERVICE USER DETAILS ONLY
Healthcare Record No ____________________________
Lead Clinician ____________________________
This incident involved… (tick one only )
Neonatal Specialties
Paediatric Specialties
Adolescent Specialties
Adult Specialties
Older Person Specialties
Incident Occurred under
(Service / Specialty)
E.g. Antenatal, Audiology,
Radiotherapy, Intellectual Disability,
Psychology
__________________________
SECTION D: STAFF MEMBER / AGENCY / PANEL STAFF
/ STUDENT / VOLUNTEER DETAILS ONLY
Category of person ____________________________
Employee no. ____________________________
Date absence commenced
(if known)
Date returned to work
(if known)
Work days lost
SECTION E: EXTERNAL CONTRACTOR DETAILS ONLY
Company name ____________________________
Company no. ____________________________
Specific Location
E.g. Ward, Clients home etc.
Note: For employee incidents reportable to HSA that result in an
absence from duty for more than three consecutive days,
excluding the day of the accident, the date absence commenced
and the date employee returned to work should be recorded on
the NIMS
