Dangerous Occurrence · Customer Self-Service

Employer Details

Name

*

Phone Number

*

Email

*

Address Line 1

*

County

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Address Line 2

*

Country

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Address Line 3

*

Eircode

*

Address Line 4

*

Incident Site Details

Address Line 1

*

County

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Address Line 2

*

Country

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Address Line 3

*

Eircode

*

Address Line 4

*

Notifier Details

Forename

*

Surname

*

Phone Number

*

Email

*

Address Line 1

*

County

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Address Line 2

*

Country

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Address Line 3

*

Eircode

*

Address Line 4

*

Dangerous Occurrences

Workplace Environment

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Incident Date

*

Approximate total number employed by Employer:

**

Dangerous Occurrence Category

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Approximate number employed at site

**

Description of Dangerous Occurrence

*