TIME OF INCIDENT* Name*
FIRST NAME
LAST NAME
DID THE INCIDENT HAPPEN ON SITEWORK* WAS ANY EQUIPMENT IN USE AT THE TIME ? IF SO LIST EQUIPMENT*
WAS ANY VEHICLE IN USE AT THE TIME ? IF SO LIST VEHICLE*
WAS ANY CLIENT INJURED AS A RESULT OF SITEWORK ? IF SO PLEASE FILL IN AN ADDITIONAL FORM*
SITE LOCATION* If SKYPARK use SKY Form
Select your answer LAND (including en route) SEA (including en route) CENTRE Other
LAND ACTIVITY* Select your answer Axe Throwing Bushcraft Campfire Container En route (Land) Gaisce walk Laser North Laser South Nightline Rockclimbing Walk (evening) Ziptopia Circus Skills Rokit Mini Olympics Carlingford Challenge Egg Drop Other
SEA ACTIVITY* Select your answer Beach Boathouse Canoe Raft Canoe Trad Canoe Trip Frenzy Double Frenzy Powerboat Pier Jumping Pontoon Raft Build Challenge Titanic Challenge BH Site SUP Trampoline Tunnel En Route Toms Yard King Johns Slipway The RIB Other
CENTRE LOCATIONS* Select your answer CENTRE ROOMS AND APARTMENTS OFFICES & RECEPTION KITCHEN CENTRE LOCATIONS OTHER LAUNDRY PINK ROOM
OFFICES AND RECEPTION Select your answer SALES OFFICE OPERATIONS OFFICE RECEPTION ACCOUNTS OFFICE MANAGEMENT OFFICE BOARDROOM Other
CENTRE LOCATION OTHER Select your answer Apartment Lane Basement Bathrooms Female Bathrooms Male Boardroom Centre lane Corridor 10's Corridor 20's Corridor 30's Corridor 40's Carpark Dundalk Street Meeting Point Carpark Dundalk Street Blue Gate Downstairs Common Room The Green Lucas Laser Lane Sports Hall Staff Accom 49A Staff Accom Dundalk St. Staff Accom Newry St. Staff Accom Windsurfer Staff Room Teachers Room Upstairs Common Room Other
CENTRE ROOMS AND APARTMENTS Select your answer Room 1 Room 2 Room 3 Room 4 Room 5 Room 6 Room 7 Room 8 Room 9 Room 10 Room 20 Room 21 Room 22 Room 23 Room 24 Room 25 Room 26 Room 27 Room 28 Room 29 Room Night Warden Room 31 Room 32 Room 33 Room 34 Room 35 Room 36 Room 41 Room 42 Room 43 Room 44 Room 51 Room 52 Room 53 Room 54 Mint 1 Mint 2 Mint 4 Mint 4 Slieve Foy 1 Slieve Foy 2 Slieve Foy 3 Slieve Foy 4 Other
KITCHEN Select your answer FLOOR FRONT FLOOR BACK GLASS CUPS PLATES CUTLERY TABLES CHAIRS SINK HOT WATER URN DISHWASHER GLASSWASHER DOOR TO MINT FRONT DOOR BACK DOOR SERVING AREA OVEN BAIN MARIE HOB CHIP FRYER PREP AREA CLEANUP SINKS PANTRY ATTIC BASEMENT FREEZERS BASEMENT DRY GOODS STORAGE Other
PINK ROOM Select your answer CHEMICALS HOOVER MOP CLEANING PRODUCTS LINEN BAGS TROLLEYS Other
LAUNDRY Select your answer WASHING MACHINE DRYER CHEMICALS LINEN TROLLEY Other
LASER NORTH ELEMENTS Select your answer Green Hut Dead Zone Castle Tunnel base Big canon Under ground base Zone 1 other Zone 2 Base 1 Zone 2 Base 1 Zone 2 Dead Zone Zone 2 element 1 Zone 2 element 2 Zone 2 element 3 Zone 2 other Zone 3 Base 1 Zone 3 Base 2 Zone 3 Dead Zone Zone 3 element 1 Zone 3 element 2 Zone 3 element 3 Zone 3 other Zone 4 Base 1 Zone 4 Base 2 Zone 4 Dead Zone Zone 4 element 1 Zone 4 element 2 Zone 4 element 3 Zone 4 other LZ North Briefing area LZ North Container
LASER SOUTH ELEMENTS Select your answer Zone 1 Base 1 Zone 1 Base 2 Zone 1 Dead Zone Zone 1 element 1 Zone 1 element 2 Zone 1 element 3 Zone 1 other Zone 2 Base 1 Zone 2 Base 2 Zone 2 Dead Zone Zone 2 element 1 Zone 2 element 2 Zone 2 element 3 Zone 2 other Zone 3 Base 1 Zone 3 Base 2 Zone 3 Dead Zone Zone 3 element 1 Zone 3 element 2 Zone 3 element 3 Zone 3 other Zone 4 Base 1 Zone 4 Base 2 Zone 4 Dead Zone Zone 4 element 1 Zone 4 element 2 Zone 4 element 3 Zone 4 other LZ South Briefing area LZ South Container
ZIPTOPIA Select your answer Platform Element Zipline Ground
ZIPTOPIA PLATFORMS Select your answer FT 1 FT 2 FT 3 FT 4 FT 5 FT 6 FT 7 FT 8 FT 9 FT 10 FT 11 FT 12 FT 13 FT 14 FT 15 FT 16 Other
ZIPTOPIA ELEMENTS Select your answer FE1 Clip & Click FE2 - Monkey Bridge FE3- Double Tightrope FE5 - Suspension Bridge FE7 - Log Bridge FE9 - Monkey Bridge FE10 - Spring Suspension Bridge FE13A- Parrot Ladder FE13B - Cross Bridge FE14 - Lilypads FE15 - Monkey Net Bridge FE16 - Net Bridge QE1A - Access Ladder QE1B - Monkey Bridge QE3 - Double Tightrope QE4 - Double Tightrope QE6 - Walking Rope QE8 - Suspended rope to Walk QE11 - Access Ladder
ZIPTOPIA ZIPLINES Select your answer FZ 1 FZ 2 Access Zip 1 FZ 3 Access Zip 2 FZ 4 Access Zip 3 FZ 5 Access Zip 4 Access Zip 5 QZ 1 Access Zip 6 QZ 2 QZ 3 Access Zip 7 QZ 4 QZ 5 Other
ZIPTOPIA GROUND Select your answer Container Training 1 Training 2 Training 3 Path to QZ1 Path along top of Quarry Path under QZ4 Other
AXE THROWING Select your answer Axe Storage Area Shooting Line Target Axe Briefing Area Waiting Area Other
BUSHCRAFT Select your answer Equipment sticks Water Fire Briefing Area Other
CAMPFIRE Select your answer Fire Benches Torches Marshmallows Parachute Water Open area between gate and campfire Other
CONTAINER LAND Select your answer Door Entrance Inside Decking Exit Step
EN ROUTE (LAND) Select your answer Tholsel Street School Crossing Savages Hill to OR No. 2 Dundalk Street School Abbey Track from No 3 OR to Sheep Dip Savages Hill Top (OR No. 3) Savages Hill Middle Church road to OR No. 3 Church Newry Street Road crossing at Savages Market Street Track from Sheep Dip to Land Gate entrance Nuns Track
GAISCE WALK Select your answer GRID REFERENCE Route D Golyn Pass track Road Junction Greenway Route C The Col Route B Windy Gap Route E Route A Other
NIGHTLINE Select your answer Turn at North End Upper Section Turn at South End Briefing Area Start Lower Section
ROCKCLIMBING Select your answer Abseil 1 Climb 4 Ground anchors Tracers Climb 5 Climb 7 Climb 2 Climb 3 Climb 1 Top anchors Bouldering Climb 8 Rockfall Abseil 2 Climb 6 Quarry Entrance Climb 9 Ropes Marquee Climb 10 Other
WALK (EVENING) Select your answer School Nuns Track Savages Hill to OR No. 2 Road crossing at Savages Market Street Newry Street Dundalk Street Tholsel Street Rooskey Road past Skypark Track from Sheep Dip to Land Gate entrance Savages Hill Top (OR No. 3) Church School Crossing Abbey Savages Hill Middle Track from No. 3 OR to Sheep Dip Church road to OR No. 3 Rooskey Road to Skypark
ROKIT Select your answer BOTTLE FRAME PUMP LAUNCH LOCATION Other
MINI OLYMPICS Select your answer The Green Sports Hall The Mint Skypark Other
CARLINGFORD CHALLENGE Select your answer LONG JUMP WEETABIX TALK TO THE APPLE HUMAN CHAIR TABLE TRAVERSE BOX GAME SHOE TOWER TALENT SHOW Option 9 Option 10 Other
CIRCUS SKILLS Select your answer DIABLOS PLATE SPINNING FLOWER STICKS POI JUGGLING UNICYCLE Other
EGG DROP Select your answer Construction Window / Height Below Drop Other
BOATHOUSE Select your answer CARPARK YARD FRONT YARD BACK BACK SLIPWAY SLIPWAY RECEPTION AREA WETSUIT ROOM CHANGING ROOM SMALL CHANGING ROOM LARGE CLIENT LOCKERS STAIRS OFFICE CONFERENCE ROOM GENTS CHANGING LADIES CHANGING INSTRUCTOR CHANGING ROOM KIT SHED Other
BOATHOUSE SITE Select your answer CARPARK YARD FRONT YARD BACK BACK SLIPWAY SLIPWAY RECEPTION AREA WETSUIT ROOM CHANGING ROOM SMALL CHANGING ROOM LARGE CLIENT LOCKERS STAIRS OFFICE CONFERENCE ROOM GENTS CHANGING LADIES CHANGING INSTRUCTOR CHANGING ROOM KIT SHED Other
BEACH Select your answer KING JOHNS BEACH FOUR SEASONS BEACH SAILING CLUB BEACH
FRENZY Select your answer CRAFT PADDLE LAUNCH RECOVERY Other
DOUBLE FRENZY Select your answer CRAFT PADDLE LAUNCH RECOVERY Other
CANOE TRADITIONAL Select your answer CANOE PADDLE LAUNCH RECOVERY Other
CANOE RAFT Select your answer CANOE YOKES PADDLE LAUNCH RECOVERY YOKE TIES Other
RAFT BUILD CHALLENGE Select your answer TRANSPORTING OF EQUIPMENT CONSTRUCTION CRAFT PADDLE LAUNCH RECOVERY
PIER JUMPING Select your answer LOW WALL HIGH WALL STEPS BENCH WATER - CONTACT END OF PIER THE PIER
PONTOON Select your answer DECK GETTING ON PONTOON GETTING OFF PONTOON Other
POWERBOAT Select your answer HULL ENGINE ANCHOR FUEL KILLCORD FUEL LINE STORAGE LOCKERS BRIDLE WARP CLEAT TRAILER LAUNCH RECOVERY Other
TITANIC CHALLENGE Select your answer CONSTRUCTION WOOD PLASTIC PIPES PADDLE LAUNCH RECOVERY
STAND UP PADDLEBOARD Select your answer RECOVERY LAUNCH BOARD LEASH PADDLE Other
TRAMPOLINE Select your answer Getting On Getting Off Frame Centre Section Inflated Ring Ropes etc. Other
TUNNEL Select your answer Tunnel Step Tunnel Entrance Tunnel Waterfall Tunnel Beach Tunnel Pipe Other
THE RIB Select your answer HULL ENGINE ANCHOR FUEL KILLCORD FUEL LINE STORAGE LOCKERS BRIDLE WARP CONSOLE JOCKEY SEAT CLEAT TRAILER LAUNCH RECOVERY Other
EN ROUTE TO BOATHOUSE Select your answer Ghan Road Harbour road Tholsel Street Carpark in front of Boathouse Carpark The Green Ghan Road crossing point 1 Ghan Road crossing point 2 Footpath at Harbour wall Road Crossing Other
TOMS YARD Select your answer DRASCOMBE SHED FUEL TANK DIESEL ENGINES BOX TRAILER FUEL TANK KEROSENE POWERBOATS EQUIPMENT RACK ENTRANCE GATE CANOE TRAILER Other
KING JOHNS SLIPWAY Select your answer Slip to Craft Slipway Craft to Slip
INJURED BODYPART Select your answer HEAD TORSO LEFT LEG RIGHT LEG LEFT ARM RIGHT ARM GENITAL AREA
HEAD PARTS Select your answer Back Front Left Right Top Forehead Face Left Face Right Chin Mouth Teeth Lips Ear Left Ear Right Nose Eye Left Eye Right Neck Hair Other
TORSO PARTS Select your answer Heart Clavicle Right Clavicle Left Chest Left Chest Right Stomach Left Stomach Left Back Spine Top Spine Middle Bottom
LEFT LEG PARTS Select your answer Thigh Hip Femur Tibia Fibula Ankle Foot Big Toe Other Toes Knee Calf Shin Other
RIGHT LEG PARTS Select your answer Thigh Hip Femur Tibia Fibula Ankle Foot Big Toe Other Toes Knee Calf Shin Other
LEFT ARM PARTS Select your answer Shoulder Humerus Elbow Radius Ulna Wrist Hand Thumb Index Finger Middle Finger Ring Finger Little Finger Other
RIGHT ARM PARTS Select your answer Shoulder Humerus Elbow Radius Ulna Wrist Hand Thumb Index Finger Middle Finger Ring Finger Little Finger Other
TYPE OF INJURY Select your answer Bleeding Bruise Bump Burn Crush Cut Disclocation Entrapment Fracture (Suspected) Hair Rash Slip Sprain (Suspected) Sting Trip Other
TRANSPORT TYPE Select your answer No Transport Required Ambulance Minibus Jeep Car Powerboat Kioti Walk Helicopter Own Transport
HOSPITAL* NO HOSPITAL REQUIRED DUNDALK DROGHEDA NEWRY Other
NATURE OF INCIDENT* Events before incident, during incident and after the incident
INJURED PARTY GROUP TYPE Select your answer CORPORATE ADULT ADULT HEN ADULT STAG YOUTH GROUP SCHOOL SECONDARY SCHOOL PRIMARY THIRD LEVEL SUMMER CAMP CAMP OTHER WEEKENDERS ENGLISH LANGUAGE STAFF
SCHOOL / COMPANY / GROUP LOCATION* COUNTY
LOUTH DUBLIN MEATH DOWN ARMAGH CARLOW CAVAN CLARE CORK DERRY DONEGAL FERMANAGH GALWAY KERRY KILDARE KILKENNY LAOIS LEITRIM LIMERICK LONGFORD MAYO MONAGHAN OFFALY ROSCOMMON SLIGO TIPPERARY TYRONE WATERFORD WESTMEATH WEXFORD WICKLOW OUTSIDE OF IRELAND (Foreign group)
TEACHER / ORGANISER /LEADER AGREES WITH DETAILS PARENT CALLED Y/N OPERATIONS / SENIOR INSTRUCTOR MADE AWARE* SENIOR NOT INFORMED ALAN LIAM PETER SARAH MATT ALEX IAN IAIN BEN
OPERATIONS CHECK* YES NO NOT INFORMED
