Incident Report Form

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

Date / Time of incident *

Date

Time

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 management of a risk, or a way of passing on positive information.

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: *

Report prepared by *

First

Last

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

Name of person reporting incident: *

Signature of person reporting incident: *

Risk Rating *

Low
Medium
High

Registered in Incident System

Date

Time

PLEASE GIVE THIS FORM TO YOUR MANAGER WITHIN 24HRS OF THE INCIDENT OCCURRING. ANY SENTINEL OR SERIOUS INCIDENTS MUST BE REPORTED TO SENIOR MANAGEMENT BY PHONE IMMEDIATELY.