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Nirf 02 V01 Crash Collision Interactive (Ireland - Health Service Executive)

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HC NIRF 02 – V01
Date issued: April 2015
NATIONAL INCIDENT REPORT FORM (NIRF)
NIRF
- 02 CRASH/COLLISION
NIMS record no.:
The purpose of the incident form is to capture and report the incident with the initial available information. This will be followed up by the relevant department / individual within the organisation.
Date of incident
Time of incident
Location
Offsite
Use 24 hour clock
The parent location the party involved was attached
to e.g. Ward in Hospital, Room in Health Centre etc.
Onsite
Type of vehicle involved…
State vehicle
3
rd
party vehicle
Registration No
.
Description of incident:
Description should be brief and factual.
Type of vehicle
Impact to vehicle
Estimate of damage
Purpose of journey
(If Sta
te vehicle)
Driver name
Injury
Qualification
(If State vehicle)
Name of vehicle owner
(If different to driver)
How many vehicles were involved
How many people were involved
(Includes drivers, passengers and/or pedestrians)
Weather conditio
ns
Other factors
Did this involve… (Tick one only)
Road/Land
Air
Water
Road conditions
Road type
Name
Injury
Name
Injury
Name
Injury
Additional passenger information… (If any)
© State Claims Agency 2015
This form has been provided solely for use by delegated State authorities that come within the remit of the State Claims Agency (as established by the National Treasury
Management Agency (Amendment) Act, 2000). The State Claims Agency does not bear responsibility for use of this from or reliance on it in any manner by any other third party.
Page 1 of 4
Y
Y
Y
Y
M
M
D
D
e.g. Car, bus, bicycle, boat, ambulance
The purpose of journey being undertaken
at the time of the crash/collision.
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
The level of driver qualification of the driver
of the vehicle.
e.g. Rear, side, front
An estimate of the repair/
replacement costs at the time of reporting
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
SECTION A: GENERAL INCIDENT DETAILS
SECTION C: VEHICLE 1 DETAILS
SECTION B: CRASH/COLLISION DETAILS
SECTION D: PASSENGER DETAILS VEHICLE 1
M
M
H
H
e.g. Rain, dry, sunny, cloudy
This allows you to identify other factors (if
any) that contributed to the crash/collision.
e.g. Flooded, icy, rough terrain
e.g. Motorway, Regional Road, National
Road, Local Road, Car Park
1
HC NIRF 02 – V01: Crash/Collision Date Issued: April 2015
Type of vehicle involved…
State vehicle
3
rd
party vehicle
Registration no.
Type of vehicle
Impact to vehicle
Estimate of damage
Purpose of journey
(If Sta
te vehicle)
Driver name
Injury
Qualification
(If State vehicle)
Name of vehicle owner
(If different to driver)
Type of vehicle i
nvolved…
State vehicle
3
rd
party vehicle
Registration no.
Type of vehicle
Impact to vehicle
Estimate of damage
Purpose of journey
(If Stat
e vehicle)
Driver name
Injury
Qualification
(If State vehicle)
Name of vehicle owner
(If different to driver)
Name
Injury
Name
Injury
Name
Injury
Additional passenger information… (If any)
Name
Injury
Name
Injury
Name
Injury
Additional passenger information… (If any)
SECTION D: PASSENGER DETAILS VEHICLE 3 SECTION D: PASSENGER DETAILS VEHICLE 2
SECTION C: VEHICLE 3 DETAILS
SECTION C: VEHICLE 2 DETAILS
e.g. Car, bus, bicycle, boat, ambulance
The purpose of journey being undertaken
at the time of the crash/collision.
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
The level of driver qualification of the
driver of the
vehicle.
e.g. Rear, side, front
An estimate of the repair/
replacement costs at the time
of
reporting
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
e.g. Car, bus, bicycle, boat, ambulance
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
The l
evel of driver qualification of the driver
of the vehicle.
e.g. Rear, side, front
An estimate of the repair/
replacement costs at the time of reporting
The purpose of journey being undertaken
at the time of the crash/collision.
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
HC NIRF 02 – V01: Crash/Collision Date Issued: April 2015
Name
Injury
Other pedestrian involved details… (If any)
Name of property owner
Type of property
Estimated damage
Other property damage details… (If any)
SECTION H: REPORTED BY:
Person who discovers the incident and unless otherwise
stated within the organisation, this person is responsible for completing the NIRF.
SECTION I: IMMEDIATE ACTION TAKEN
First name
Surname
Date notified
D
D M M Y
Y Y Y
Category of person
g. Nurse, Catering Staff, Cleaner
Local system reference no.
SECTION F: SKETCH CRASH/COLLISION
SECTION E: PEDESTRIAN DETAILS
SECTION G: PROPERTY DAMAGE (NON VEHICLE)
e.g. Fracture, sprain, stress, laceration,
swelling, bruising
This is an estimate of the repair/
replacement costs at the time of reporting
e.g. Wall, gate, pillar
SECTION J: OPEN DISCLOSURE DETAILS
Was open disclosure required?
Yes No
D D
M M
Y
Y
Y Y
Date of open disclosure
Time of open disclosure
H
H M M
Use 24
hour clock
Any additional open disclosure details:
HC NIRF 02 – V01: Crash/Collision Date Issued: April 2015
SECTION K: WITNESS DETAILS (Name, contact no. etc.)
SECTION L: 3RD PARTY CONTACT DETAILS
Section M: SIGNATURES
Reporters Signature
Date
D D M M Y
Y Y Y
Title
Line Managers Signature
(where required)
Date
D D M M Y
Y Y Y
Title
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Completed 18 July 2020

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