Adverse Incident IR1 Report Form Ref No: Insert Reference Number.

Details of Incident
Date: / Click here to enter a date. / Time: / Click here to enter time. / Incident No: / EnterIncident Number /
Location
Premises No/Name: / Premises name/No / Street: / Street /
Town: / Town / County: / County / Postcode: / Postcode /
Type of Incident (Please tick one or more as appropriate)
☐ / Fire / ☐ / Equipment / ☐ / Personal Accident
☐ / Near Miss / ☐ / Assault / ☐ / Ill Health
☐ / Patient/Manual Handling / ☐ / Security / ☐ / Estates/Buildings
☐ / Clinical Risk / ☐ / Violent Incident / ☐ / Patient Confidentiality
☐ / Vehicle / ☐ / Telecommunications/Media / ☐ / Theft
☐ / Welfare / ☐ / Inter-Agency Issue / ☐ / Waiting area
☐ / Frequent/Hoax Caller / ☐ / Control of Infection / ☐ / Mental Health
☐ / Finance / ☐ / Information Governance / ☐ / Other
If ‘Other’, please specify
Did the Incident Result in Injury/ill Health? / ☐ / Yes / ☐ / No
Has the appropriate Manager for the types of incident/s ticked above been notified? / ☐ / Yes / ☐ / No
If ‘Yes’ please specify the name of that Manager / Manager’s name here /
Details of Person Injured/Involved
☐ / Staff / ☐ / Patient / ☐ / Member of the Public
☐ / Other Medical Staff / ☐ / Contractor / ☐ / Other
Name of Person Injured/Involved: / Click here to enter text. / Occupation/Title: / Click here to enter text. /
Premises No/Name: / Premises name/No / Street: / Street /
Town: / Town / County: / County / Postcode: / Postcode /
Date of Birth: / Click here to enter a date. / Telephone number: / Insert Telephone Number /
Nature of Injuries
☐ / None / ☐ / Low / ☐ / Moderate / ☐ / Severe / ☐ / Death
Has it been necessary to stop work? / ☐ / Yes / ☐ / No
Estimated duration of absence: / Click here to enter duration. / Date last worked: / Click here to enter a date. /
Equipment
Type of Equipment: / Type of Equipment. / Model Number: / Model Number /
Serial Number: / Serial Number / Batch Number: / Batch Number /
Current Location of Equipment: / Location of Equipment / Removed from service? / ☐ / Yes / ☐ / No
Violent Incident
Name of Assailant: / Name of Assailant /
Premises No/Name: / Premises name/No / Street: / Street /
Town: / Town / County: / County / Postcode: / Postcode /
Police Informed? / ☐ / Yes / ☐ / No / Name of Officer dealing with incident: / Name of Officer /
PC Shoulder No: / PC Shoulder No / Station: / Station / Crime URN No: / Crime No /
Type of Incident: / ☐ / Verbal Abuse / ☐ / Physical Abuse / ☐ / Sexual Abuse
☐ / Racial Abuse / ☐ / Drugs Involved / ☐ / Alcohol Involved
Weapon Involved? / ☐ / Yes / ☐ / No / If ‘Yes’ please specify type / Type of weapon /
Damage to property? / ☐ / Yes / ☐ / No
Description of Incident
Initial Report by: / ☐ / Witness or / ☐ / Staff member
Name of witness/staff member: / Click here to enter text. / Telephone No: / Click here to enter text. /
Address of witness/staff member: / Click here to enter text. /
Description of Incident:Please include vehicle registration number if applicable and also actual location within the building. (Please attach a separate sheet for additional comments. DO NOT write on the back of these forms)
Click here to enter text. /
Risk Rating 1 (tick as appropriate)
Impact / ☐ / Insignificant (1) / ☐ / Minor (2) / ☐ / Moderate (3) / ☐ / Major (4) / ☐ / Catastrophic (5)
Likelihood / ☐ / Rare (1) / ☐ / Unlikely (2) / ☐ / Possible (3) / ☐ / Likely (4) / ☐ / Almost Certain (5)
Total Risk Score (Impact x Likelihood): / Click here to enter text. /
Name: / Click here to enter text. / Date / Click here to enter a date. /
Signed
Line Manager Investigation Outcomes And Remedial Actions Taken
Name of Line Manager: / Click here to enter text. / Telephone: / Click here to enter a date. /
Description of Line Managers investigation of the initial report including any immediate actions taken and any investigation outcomes.
Click here to enter text. /
Risk Rating 2 (rating should be completed as soon as possible after the incident and after remedial actions undertaken, tick as appropriate)
Impact / ☐ / Insignificant (1) / ☐ / Minor (2) / ☐ / Moderate (3) / ☐ / Major (4) / ☐ / Catastrophic (5)
Likelihood / ☐ / Rare (1) / ☐ / Unlikely (2) / ☐ / Possible (3) / ☐ / Likely (4) / ☐ / Almost Certain (5)
Total Risk Score (Impact x Likelihood): / Click here to enter text. /
Signed / Date / Click here to enter a date. /
Does this Incident require escalating to Senior Management? / ☐ / Yes / ☐ / No
If ‘Yes’ please fill out the following section…
Senior Management Investigation Outcomes And Remedial Actions Taken
Name of Senior Manager: / Click here to enter text. / Telephone: / Click here to enter a date. /
Description of Senior Management investigation of the incident including any immediate actions taken and any investigation outcomes.
Click here to enter text. /
Risk Rating 3 (rating should be completed after investigation and further remedial actions by senior management, tick as appropriate)
Impact / ☐ / Insignificant (1) / ☐ / Minor (2) / ☐ / Moderate (3) / ☐ / Major (4) / ☐ / Catastrophic (5)
Likelihood / ☐ / Rare (1) / ☐ / Unlikely (2) / ☐ / Possible (3) / ☐ / Likely (4) / ☐ / Almost Certain (5)
Total Risk Score (Impact x Likelihood): / Click here to enter text. /
Signed / Date / Click here to enter a date. /
Feedback to Staff
Description of any feedback to staff regarding the Incident. Please include details of how feedback was given, who it was given by and who it was given to; also how the feedback was received and any reflections on the incident.
Click here to enter text. /
Name: / Click here to enter text. / Date / Click here to enter a date. /
Signed
Root Cause Analysis
RCA to be conducted? / ☐ / Yes / ☐ / No / RCA Conducted? / ☐ / Yes / ☐ / No
Supplementary Reporting
☐ / CQC / ☐ / RIDDOR / ☐ / NPSA / ☐ / MHRA / ☐ / CFSMS
☐ / Police / ☐ / Feature / ☐ / Other NHS Bodies
Reviewed by Clincial Governance (QGPS&R)
Name (please print): / Click here to enter text. /
Signed / Date / Click here to enter a date. /
Additional Comments
Click here to enter text. /
Name: / Click here to enter text. / Date / Click here to enter a date. /
Signed
EBPCOOH/CG/MBRev 78/2012
IR1 Form