Incident Report Form

Hopefully, there will never be an incident that needs to be written up, but we always need to be mindful that accidents and medical emergencies can happen, no matter how careful we are. A report should be completed as soon as possible, with as much detail as possible. Specify right and left, arm, leg or shoulder, for example and list injuries specific to the incident.

Below is a sample of an Incident Report Form

To be completed by staff on the day of the incident

Incident Date: _________ Incident Time: __________ Place of Incident:_________________

Injured Person’s Name: _________________________________ Preferred Pronoun _______

Emergency Contact (sourced from the Medical Waiver). Name:________________________________________________________________________

Emergency Contact Mobile: ______________________________________________________

Has Emergency Contact been notified? Yes/No

Details of Incident: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Injury Type: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Was first aid required? Yes/No.

If yes, what was the procedure? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Was an ambulance called? Yes/No

Does Injury require Hospital/Doctor? Yes*/No**

*If yes,
Name of Hospital/Doctor _____________________________________________________________________________

Address: _____________________________________________________________________________

**If no, what treatment and care was given ____________________________________________________________________________

Other Details:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Witness/Witnesses:

Name: _____________________________________ Signature: _________________________

Report Prepared By:

Name: ___________________________________ Position or Role _____________________

Signature:_____________________________________________________________________

Date: _____________________________________________________________________________