HC NIRF 04 – V07
Date issued: 20/03/2020
NATIONAL INCIDENT REPORT FORM (NIRF)
NIRF – 04 DANGEROUS OCCURRENCE/REPORTABLE CIRCUMSTANCE
NIMS record Number:
Page 1 of 2
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
Date of incident
Time of incident
Use 24 hour clock
Location
_______________________________________________________________________________________
Onsite
Description of incident:
SECTION B: WHAT TYPE OF OCCURRENCE DID THIS RELATE TO?
(Tick 1 option from
Sub Hazard, Please Specify & Problem/Cause)
Sub Hazard Type Please Specify Problem/Cause
Staff Factors
Competence
Equipment Resources
Knowledge and Skills
Breached/Non-Compliant
Inadequate/Insufficient
Organisational &
Management Factors
Fire Regulations
Infection Control Policy
Medication Safety Policy
Other Protocols/
Policies/ Regulations
Smoking Policy
Security
Other, Please Specify
__________________
Environmental Factors
Food Safety
General Hygiene
Noise Level
Overcrowding
Disposal of Clinical Waste
Pest Control
Work Environment
Water Supply
Other, Please Specify
____________________
Systems / Installations
CCTV Systems
Electrical Installation
Fire Systems
IT Systems
Power
Telephone/Bleeper Systems
Other, Please Specify
____________________
Occupational Disease
Anthrax
Malaria
Measles
Other, Please Specify
_________________
HSA Dangerous Occurrence
Building under
Construction/Demolition
Breathing Apparatus
Closed Vessel
Dangerous
Substance/Pathogen
Explosives
Flammable Chemical
Load Bearing Part
Pipeline
Plant/Place
Revolving Mechanical
Component
Scaffolding
Vehicle/Tank Carrying
Dangerous Substance
Vehicle/Train/Locomotive
Walls/Floors of Building
Other, Please Specify
___________________
Accidental Collision
Burst
Collapse
Contact with Overhead Lines
Explosion
Failure
Fire
Ignition
Overturning
Uncontrolled/Accidental
Release
Other
Staff Resources
Other, Please Specify
____________________
Inadequate/Insufficient
Unavailable
Notifiable
Unnotifiable
Breached/Non-Compliant
Failure
Inadequate/Insufficient
The description should be brief and factual
Breached/Non-Compliant
Failure
Inadequate/Insufficient
Offsite
COVID-19
HC NIRF-04 Page 2 of 2
SECTION D: REPORTED BY: person who discovers the incident and unless
otherwise stated within the organization, this person is responsible for completing the NIRF.
First name
__________________________________
__________________________________
E.g. Social Worker, Pubic Health Nurse, etc.
__________________________________
Surname
Date notified
Category of person
Local system
reference no.
SECTION E: WITNESS DETAILS (Name, Contact No. etc.)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
SECTION C: IMMEDIATE ACTIONS TAKEN
SECTION F: OPEN DISCLOSURE DETAILS SECTION G: NOTES
Was open disclosure required? (tick one only )
Yes No
Date of open disclosure:
Time of open disclosure:
Use 24 hour clock
Any further information?
SECTION H: SIGNATURES
_____________________________________________
Reporter Signature:
Title:
__________________________________
Date:
Line Manager Signature:
(where required)
Title:
_____________________________________________
__________________________________
Date:
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