northerncare - Accident & First Aid Incident Report Form | Accident/Treatment Ref No. | 160411-1900-AB | | | | This section can be completed by the injured person, a responsible person on behalf of an injured person, or a responsible person reporting the incident They should complete parts A, B, C and D. The injured person should sign or initial their consent for information to be shared Please complete in block capitals. |
A. About the person injured/involved | 1. Name | 2. Home address and post code | 3. Home phone number | 4. Age | | 5. | Male | 5. | | 4. | Female | 6. Status of injured person (Tick applicable box) Northern Care Employee. Client/Young person. (Go on to B) On student placement. Someone else's employee. (E.g. contractor) Member of public/visitor. 7. Job title/occupation | 8. Department.eg. unit, office | 9. If 'Someone else's employee' give name & phone number of employer | | |
B About the incident | 1. Type of incident (Tick applicable box) Near miss/ accident not resulting in injury Accident resulting in injury Physical Intervention/Restraint Self Harm Violent incident (Physical or verbal) Antisocial Conduct (not violence but causing distress) Dangerous Occurrence Work related/Ill health
2. | Date of Incident/onset of illness | 3. Time of Incident (24 hr clock) | | | | | |
4. Address where incident happened | 5. Exact location at the above address |
6. Describe task or activity taking place and what happened | |
C. Outcome of the incident How was the person involved affected? Near miss/No injury Minor injury Unconscious/needed
