HC NIRF 02 – V01
Date issued: April 2015
NATIONAL INCIDENT REPORT FORM (NIRF)
NIRF
- 02 CRASH/COLLISION
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.
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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