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Injury Incident Report Form: To Be Completed by Staff Within 12 Hours of Incident/accident

This injury incident report form is to be completed within 12 hours of any incident or accident. It collects information about the injured person such as their name and address, details of the incident, type of injury, and whether medical attention was required. The form is to be prepared by staff and approved by management to document the incident details and next steps.

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95 views1 page

Injury Incident Report Form: To Be Completed by Staff Within 12 Hours of Incident/accident

This injury incident report form is to be completed within 12 hours of any incident or accident. It collects information about the injured person such as their name and address, details of the incident, type of injury, and whether medical attention was required. The form is to be prepared by staff and approved by management to document the incident details and next steps.

Uploaded by

lrac_adazol
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Injury Incident

Report Form

To be completed by staff within 12 hours of incident/accident

Incident Date: _______________________________ Incident Time:


_______________________

Injured Person Name:


_____________________________________________________________

Address:
_________________________________________________________________________

Details of Incident:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Who was injured person?


_________________________________________________________

Injury Type:
Does Injury require Hospital/Physician? Yes: ___________________ No:
__________________

Hospital Name:
_____________________________________________________________
Address:
___________________________________________________________________

Important Notes and Instructions:


_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Prepared By: ______________________________ Date:


________________________________
Name of Approved By: ______________________________ Signature:
____________________

Incident Report
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