INCIDENT REPORT FORM
To be completed by staff within 12 hours after the incident/accident
Incident time: __________________________________ Incident date: ____________________________
Injured person name: _____________________________________________________________________
Address: ________________________________________________________________________________
Phone Number:__________________________________________________________________________
Date of Birth:____________________________________________________ Gender:_________________
Details of incident:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Injury type: ______________________________________________________________________________
Does Injury require Hospital/Physician? Yes/No
Hospital Name:___________________________________________________________________________
Address:_________________________________________________________________________________
Hospital Phone Number:____________________________________________________________________
Important Notes/Instructions:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Prepared By:____________________________________________ Date:____________________________
Name of Approved By:_____________________________________ Signature:________________________