GC Fitout Incident Report Form – Docusafe Back to Docusafe GC Fitout Incident Report Form To be completed by all GC Fitout Personnel "*" indicates required fields Project Name*Select ProjectLufthansa CelbridgeTSL Primark Newbridge ProjectRetail in Motion, 11 Cherrywood Business ParkUnit 8, Richview Office ParkNeoen Ferry HouseBottleworksBausch & LombTSL IPUT Unit 1TSL IPUT Unit 4The Wren HotelMonk ProjectTirlan Citywest Office FitoutEmail Injured Party: Full Name* First Last Address: Home / Company*Date of Birth* DD slash MM slash YYYY Sex* Male Female Please tick the appropriate category below* Public Visitor Contractor Sub-Contractor Other Date of the accident* DD slash MM slash YYYY The date of the accident reported* DD slash MM slash YYYY Type of the accident* Injured by a person Struck by or contact with Road traffic accident/crash Exposure to substances and environment Manual handling Property Damage Other Type of injury* Fatality Bruise Concussion Internal Injury Abrasion Fracture Sprain Torn ligaments Burns Scalds Frostbite Trauma Occupational Disease Other Part of the body injured* Head (except eyes) Eyes Face Neck, back, spine Chest, abdomen Shoulder Upper arm Elbow Lower arm, wrist Hand Finger (one or more) Hip joint, thigh, kneecap Knee joint Lower leg Ankle Foot Toe (one or more) Multiple injuries Trauma, shock Other Consequence* Fatal Non-Fatal Result* Sick Leave Excused Light Duty Excused Anticipated Absence* 1 - 4 4 - 7 8 - 14 More than 14 days NONE, i.e. no anticipated absence on resulting from the accident or incident. Have you informed your insurance company?* Yes No Not applicable Work being carried out when the accident occurred* Full description of the equipment used, if any* Witness 1 - Name* Witness 1 - Company Name* Witness 1 - Statement* Witness 2 - Name Witness 2 - Company Name Witness 2 - Statement Investigator Name* Date* DD slash MM slash YYYY Name of person completing the form. First Last Signature of person completing the form.