Statutory notification of incidents in
designated centres for children and
adults with disabilities
NF05D
Form
Notification of any unexplained absence of a
resident from the designated centre
Regulation 31 (1) (e) of the Health Act 2007 (Care and Support of Residents in
Designated Centres for Persons (Children and Adults) with Disabilities) Regulations
requires that:
The person in charge shall give the Chief Inspector notice in writing within 3 working
days of any unexplained absence of a resident from the designated centre.
For details on how and when to complete this form, please refer to our guidance for
registered providers and persons in charge about the statutory notification of incidents in
designated centres.
1. Provider Details
Name of individual service unit:
Name of the centre:
Centre ID:
Registered Provider:
Person in Charge:
Address of the centre:
Date form completed:
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2. Details of the absence
Please identify below the individual residents affected using resident unique identifier1
Resident’s Unique Identifier:
Date absence occurred:
Time absence was
first noticed:
Length of absence: (in hours)
3. Had this resident been identified as being at risk in this regard?
Please comment:
4. Circumstances of the absence
Outline the circumstances of the absence:
5. Current status of the resident
Describe the current status of the resident, for example physical and/or mental state:
1
Please refer to back page for guidance on the use of a unique identifier.
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6. Immediate actions taken
Outline immediate actions taken:
7. Measures taken
What measures2 have you taken to ensure that all residents are safe?
8. Additional information
Additional information pertinent to the absence including details of notification of incident to resident’s
family and Garda:
Declaration:
I, the undersigned, declare that the information I have provided in this notification form is true
to the best of my knowledge and belief.
Name:
(please print)
Signed:
Date:
Position:
(If not the Person in Charge)
Telephone Number:
As per Regulation 23 of the Health Act 2007 (Care and Support of Residents in Designated Centres
for Persons (Children and Adults) with Disabilities) Regulations
2
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On completion of this form
Please return the completed signed form by email to rst@hiqa.ie (designated
centres for adults or adults/children) or children@hiqa.ie (designated centres for
children-only).
Please note:
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Where it is not possible to email the form, you should return it by post or fax
to an address below
When a fully completed and signed form has been emailed to the Authority,
there is no need to also post or fax a copy
Please mark faxes for the attention of ‘Regulatory Support Team’.
Regulatory Support Team
Health Information and Quality Authority
Dublin Regional Office
Georges Court
Georges Lane
Smithfield
Dublin 7
Tel: 01 814 7400
Fax: 01 814 7499
Guidance on the use of a unique identifier:
In line with data protection principles and privacy impact assessment, the Authority
will only collect information necessary to carry out its statutory functions. This
means that Authority will not unnecessarily collect personal information. Therefore,
providers are asked not to include personal information on a resident when
submitting a notification to the Authority. This includes naming a resident or
providing a date of birth on the form.
Registered providers should create a unique identifier for each of their residents.
The identifier should be created so as not to allow for individuals to be identified.
Identifiers should be numerical; however, dates of birth, admission dates, room
numbers or other data that could potentially identify a resident should not be used.
A method of validating the unique identifiers should be kept securely in the centre
and made available to inspectors on request.
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