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Ireland forms for Health Service Executive

BROWSE IRELAND - HEALTH SERVICE EXECUTIVE FORMS

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HCW Covid-19 NIRF: V01
Date issued: 05/2020
Healthcare Worker COVID-19 Acquired
NATIONAL INCIDENT REPORT FORM (NIRF)
NIMS record Number:
Page 1 of 2
This form should be completed where a staff member/volunteer/external contractor/work placement student acquires COVID-19. For all other COVID-19 related
incidents and dangerous occurrences please follow normal incident reporting processes.
SECTION A: GENERAL INCIDENT DETAILS
Date of incident
Time of incident
Use 24 hour clock
Location
Specific Location
E.g. Ward, Clients home etc.
Offsite?
SECTION B: PERSON AFFECTED DETAILS
First name
____________________________________
Surname
____________________________________
Date of birth
Female
Male
Description of incident:
Please provide as much detail as possible at the time of incident reporting; e.g. date symptomatic, date tested, possible cause
of transmission e.g. PPE unavailable, lack of communication, insufficient isolation/quarantine etc.
and the immediate action taken e.g. isolate for 14 days etc.
SECTION C: WHO WAS INVOLVED…? (tick one only )
Staff member
Agency / Panel staff
Volunteer
Student
External Contractor
SECTION D: DIVISION (tick one only )
Acute Hospital
Social Care
Health and Wellbeing
Primary Care
Mental Health
Ambulance Service
SECTION E: STAFF MEMBER / AGENCY / PANEL STAFF
/ STUDENT / VOLUNTEER DETAILS ONLY
Category of person
__________________________________
Employee no.
__________________________________
Date absence
commenced
(if known)
Date returned to
work
(if known)
SECTION G: EXTERNAL CONTRACTOR DETAILS ONLY
Company Name __________________________________
Company no. __________________________________
SECTION F: IS THIS LINKED TO A PREVIOUSLY REPORTED
INCIDENT? (tick one only )
Yes
No
If yes, please give record no(s).
SECTION H: WAS THERE WORK RELATED CONTACT? (as
defined by HPSC & Occupational Health) (tick one only )
Known close contact (work related)- Go to section I
Known casual contact (work related) - Go to section I
No known contact (work related)– Go to section J
HCW Covid-19 NIRF-01
Page 2 of 2
SECTION K: WHAT WAS THE OUTCOME AT THE TIME
OF THE INCIDENT?
Outcome
Injury not requiring first aid
Category 3
Injury or illness, requiring first aid
Injury requiring medical treatment
Category 2
Long-term disability / Incapacity (incl.
psychosocial)
Category 1
Permanent Incapacity (incl.
Psychosocial)
Death
SECTION L: REPORTED BY:
First name
_________________________________
Surname
_________________________________
Date notified
Category of person
E.g. Consultant, Nurse, Allied Health etc.
Local system
reference no.
_________________________________
Reporter Signature:
_________________________________
Date
Contact Details
___________________________________
SECTION M: TO BE COMPLETED BY LINE/DEPARTMENT
MANAGER (CATEGORY 1 INCIDENTS ONLY)
SAO Name:
Date notified to SAO:
SAO Email and Contact Details:
_______________
_______________
Line/Department Manager name:
______________________________________________
Date:
SECTION O: TO BE COMPLETED BY QUALITY AND
PATIENT SAFETY OFFICE
QPS Advisor
Name:
____________________________________
Date:
SECTION N: WITNESS DETAILS (Name, Contact No. etc.)
SECTION I: CAUSE OF TRANSMISSION/POSSIBLE
TRANSMISSION: (select max 3)
Hygiene practices, cough etiquette and cleaning regimes
Insufficient isolation/quarantine
Lack of Communication
Movement/transfers (transportation)
PPE available not utilised
PPE inadequate/failure/breached
PPE unavailable
Social distancing failures
Contact tracing incomplete/not completed
Delay in detecting case
Derogated worker
Engineering controls/facilities inadequate e.g. design,
layout, ventilation
False negative result
Poor waste management
Undetected case
Violence, Harassment and Aggression
SECTION J: HAZARD CLASSIFICATION:
Sub-hazard:
Biological
Virus
Problem/Cause (route of transmission)
Exposure to Bite (Human)
Exposure to Bite (Insect / Animal)
Exposure to Bodily Fluids
Exposure to Needle Stick
Inhalation/Airborne
Equipment, Implements, Facilities, Sharps (Non Needle)
Unknown
Other: ________________________________
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Completed 12 August 2021

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