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:
