Dangerous Occurrence · Customer Self-Service

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Employer Details

Name

Phone Number

Email

Address Line 1

County

Address Line 2

Country

Address Line 3

Eircode

Address Line 4

Incident Site Details

Address Line 1

County

Address Line 2

Country

Address Line 3

Eircode

Address Line 4

Notifier Details

Forename

Surname

Phone Number

Email

Address Line 1

County

Address Line 2

Country

Address Line 3

Eircode

Address Line 4

Dangerous Occurrences

Workplace Environment

Incident Date

Approximate total number employed by Employer:

Dangerous Occurrence Category

Approximate number employed at site

Dangerous Occurrence Sub-Category

Description of Dangerous Occurrence