Accident/Incident report form

To be completed by staff within 2 Hours of incidents/accidents (where possible)

Your name

First Name

Last Name

Date / Time of incident

Service user involved

Any other witnesses?

Please make sure you provide a detailed report:

Exactly where were you when the accident/incident occurred?

What was you doing leading up to the accident/incident?

How did the accident/incident occur?

How did you resolve the accident/incident?

Emergency services called

Yes

Transferred to hospital?

Yes

Name of person reported to in the office

First Name

Last Name

Incident Logged in Care notes?

Yes

Staff signature

First Name

Last Name

witness signature

First Name

Last Name

Any first aid administered on site?

Yes

if ‘yes’ give brief description below and refer to Body Mapping

Body map to show the Nature and Extent of any injuries

Name of vulnerable person

These diagrams are designed to help you record any visible signs of harm or injury. Shade and label and bruises, cuts, burns and so on. Label any parts of the body where any internal injuries have been identified as a result of a medical examination. If injuries are evident in soft0tissue parts of the body, such as the neck, under arms, stomach, genitals or inner thighs, these are unlikely to have occurred as a result of a fall or accident.

Do not worry if this information is not available at this stage it can be documented as part of the investigation. If that is more appropriate.

Upload body map picture here

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Name of person who completed the form

First Name

Last Name

Signature

Date / Time

Accident/Incident report form

To be completed by staff within 2 Hours of incidents/accidents (where possible)

Your name

Please make sure you provide a detailed report:

Name of person reported to in the office

Body map to show the Nature and Extent of any injuries

Name of vulnerable person

Name of person who completed the form

With a client base of over 10,000+ and a pack of hungry locums over 5000 strong, come and get cracking!

Get in touch!

Additional Information

Opening Hours

To be completed by staff within 2 Hours of incidents/accidents (where possible)

Your name

Please make sure you provide a detailed report:

Name of person reported to in the office

Body map to show the Nature and Extent of any injuries

Name of vulnerable person

Name of person who completed the form

With a client base of over 10,000+ and a pack of hungry locums over 5000 strong, come and get cracking!

Get in touch!

Additional Information

Opening Hours

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