Incident Report Form – Part 1

Tobe completed by staff member or individual reporting the incident(Respond in 24 hours)

Head Office Incident No (Allocated by HO staff):

Details of Individual Reporting the Incident

Name: / Date of Birth:
Home Address: / Postcode:
Please tick () / Male / Female / Employee / Visitor / Service User / Other

Details Of The Incident

Incident Address:
Date of Incident: / Time of Incident:
Confirm Category/Categories from Incident Pick List:(Choose between Letter A to N)
Confirm Pick List No(s) between 1 – 74:
Project
Describe as fully as possible, in your own words, and step by step what happened in the incident. Where possible, provide details of what happened leading up to the event, during and afterwards- to the best of your ability. Include where it happened, how it happened, and the nature of any injury. Record facts, times, people involved,dates, reason if known, and outcomes. If you are not the injured person, please include the injured/affected person`s details on page 2. Response Time - 24 hours

Continue on a separate sheet if required

To Be Completed By Head Office

Date Logged / Passed to Catherine Sloey (PA to Chief Executive) and Regional Manager / Yes / No / Completed
Please Note – If urgent, contact Line Manager or On-call Manager immediately and ensure that this form is completed and forwarded to Head Office for the attention of the Area Manager and Catherine Sloey (PA to Chief Executive) next day.
Action Taken/People Contacted: (please tick)
1) On call / 4 ) Family/Next of Kin / 7) Care Manger
2) NHS 24 / 5) Child Protection Notification and/or AP1 / 8 ) Line Manager
3) Emergency Services / 6) Care Inspectorate / (9) Other please state
Did the person receive any treatment? If so give details of what treatment was given and by whom
Give details if there was any damage to property or equipment

Details of the injured person, if not the person(s) completing this report. Also include people who were involved in the incident.

Name / Name
Employee / SU / Visitor / Employee / SU / Visitor
Member of public / Other / Member of public / Other
Address
Postcode / Address
Postcode
Tel
contact / Tel
contact

Details of People who saw or heard the incident

Names and Position / Contact Details
Date / Signature(s)
Do you give consent to your employer to disclose personal information and details of the accident/incident which appear on this form to safety representatives and representatives of employee safety for them to carry out the health and safety functions given to them by law? / (Please tick )
Yes
No

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Reviewed by: Chief Executive / Issue no: 3 / Issue date: July 2013 (Part 1)