Health and Safety

Health & Safety Incident/Near Miss Report Form

Note: Where there is Injury involved the DCU Injury/Incident Report Form must also be completed:
(Available from all school offices/Health & Safety Office)

General Details of the Incident
Date
Time am/pm
Building Name & Room Number
Outdoor Location (Indicate nearest building)

Person Completing Report
Name in full
Are You (select one of the following)
University Employee
Student
Visitor
Contractor

School/Unit
Email Address
Contact Number
Details of the Incident (Describe what happened)

Cause of the incident
In your opinion what action should be taken to prevent recurrence

If you have identified a building fault/maintenance issue please also report on maintenance database – link - https://www.dcu.ie/estates/helpdesk/Login.aspx

Reported on maintenance database	Yes	No