ADMIN FORM - Accident and Incident Record Form

Please complete this form in as much detail as possible with the facts of the accident/incident.

SECTION ONE

DETAILS OF ACCIDENT/INCIDENT
Name of Person Completing the Form Name of Person Completing the Form First Last
Date of incident or accident Date of incident or accident / DD / MM YYYY
Address where accident/incident took place Address where accident/incident took place
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of person or people involved
Nature of accident/incident

Nature of accident/incident Behavioural Breach of policy Medical Medication Error Motoring or damage to vehical Out of Hours On Call Emergency Staff Member Injured Service User Injured School Refusal Near Miss Other (Please detail below) Other (Please detail below)
Was anyone injured

Was anyone injured Yes No
If Yes, please provide name and address of this person/people.
SECTION TWO

EXPLANATION OF ACCIDENT/INCIDENT
Give details of how and precisely where the incident took place and the extent of any injury.
Describe what activity was taking place, for example training/game/getting changed.
Please upload any files that evidence what happened in this incident.
THIS IS ONLY TO BE USED WHEN THERE IS DAMAGE TO PROPERTY.

Attach Files
Attach Files
Attach Files
Attach Files
SECTION THREE

ACTIONS AND/OR TREATMENT IMMEDIATELY AFTER ACCIDENT/INCIDENT
Give full details of action taken during any first aid treatment and the name(s) of first-aider(s)
Were any of the following contacted?

Were any of the following contacted? Parent/Carer Police Ambulance CQC None
What happened to the injured person following the incident/accident?
E.g. carried on with session, went home, went to hospital etc.
By submitting this form you are confirming that all of the above facts are a true record of the accident/incident.

ADMIN FORM - Accident and Incident Record Form

ADMIN FORM - Accident and Incident Record Form

SECTION ONE

SECTION TWO

SECTION THREE

By submitting this form you are confirming that all of the above facts are a true record of the accident/incident.