This Injury Incident Form report template is created after an incident happens, which means when something that happens, possibly as a result of something else, has to be reported, because it did damage. A commonly used incident, is for example of an incident is noticing an airplane in the sky, while taking a walk (a particular occurrence, especially one of minor importance to the person). However, the incident (accident) that this report type is referring to, has more to do with a violation of the law, for example the incident where someone is going to jail after being arrested for shoplifting. Something incident to something else. This sample Accident Incident Report template can help you find inspiration and motivation. This Sample Accident Incident Report covers the most important topics that you are looking for and will help you to structure and communicate in a professional manner with those involved.
Closed fracture Dislocation Sprain, torn ligaments
Suffocation, asphyxiation Gassing Drowning Poisoning Infection Burns, scalds and frostbite Effects of radiation Electrical injury Property damage, Specify
- Other, Specify Indicate part of body most seriously injured (put an ‘x’ in one box only):
- Head, except eyes
- Fingers, one or more
- Hip joint, thigh, knee cap
- Knee joint, lower leg, ankle
- Back, spine
- Toes, one or more
- Extensive parts of the body Shoulder, upper arm, elbow Multiple injuries Lower arm, wrist, hand Other, Specify Consequences of the Accident/Incident:
- Anticipated absence if not Date of resumption of work back Fatal if back 4-7 days Non Fatal Year Month Day 8-14 days More than 14 days
- Doctor’s report and recommendation:
- Steps taken to prevent reoccurrence of this type of Accident/Incident: Signature of person completing report: Date: Print Name Job Title: Signature of Head of Department/School/Function: Date: Print name: (Copies of the completed Institute Accident Report are to be sent separately to the Institute Health Safety Co-ordinator, the Vice President for Finance Corporate Affairs and the Estates Office).
Feel free to download this intuitive healthcare incident report template that is available in several kinds of formats, or try any other of our basic or advanced templates, forms or documents. Don't reinvent the wheel if an accident/incident happens for the first time, that is worth recording. Make sure the information is logged well in the report, so it can be a point of reference in the future if needed.
Download this Health Accident/Incident Report Form template and save yourself time and effort! You will see completing and submitting your incident form just became a little easier.