Incident Report Form

Remember you have a responsibility to report an incident immediately, and to implement immediate strategies to mitigate further risk issues.

DO NOT Use this form for Clinical Incidents. This is a Health Service wide reporting tool. Information can include (but not be restricted to) after hours communication, competencies, complaints, equipment failure, incidents, inappropriate behaviors, failure of procedures, intruders, or any other issues of concern. They can also be used as a proactive means of notifying team leads and function leaders of a risk, or a way of passing on positive information.

Date / Time of incident: *

Date

Time

Do you want this report to remain confidential? *

Do you want feed-back on this report? *

Patient ID (if patient was involved):

Location of incident: *

Was this incident a breach of policy? *

Details of incident: *

Were there any witnesses to this incident? If so whom? *

Name of person reporting incident: *

Signature of person reporting incident: *

Clear Signature

Date / Time incident form lodged:

Date

Time

PLEASE GIVE THIS FORM TO YOUR DIRECT REPORT WITHIN 24 HOURS OF THE INCIDENT OCCURRING. ANY SENTINEL OR SERIOUS INCIDENTS MUST BE REPORTED TO YOUR FUNCTION LEADER BY PHONE IMMEDIATELY.