Incident, Adverse Event or Near Miss Report Form (IR1)
This form is to be completed by staff who undertake work on behalf of Primary Ambulance Services. It is used to report Clinical and Non Clinical incidents, Accidents or Near Misses, whether or not an injury has occurred. You should call the Primary Ambulance Services "On Call" Manager in addition to completing this report.
Incident Date and Time:
Name of the Person Reporting the Incident:
firstname.lastname@example.org - So that we can contact you if we need further information.
Please enter a valid phone number, so that we can contact you if we need further information, or to perform a welfare check.
Staff Role at the time of the Incident:
e.g. Duty Manager, ACA, First Aider etc.
Location of the Incident:
Where did it occur - Give full details
Names, Roles and Details of anyone else involved.
You should include contact details for anyone non connected with Primary Ambulance Services.
Give a Full Description of the Incident, Adverse Event or Near Miss:
Keep it factual and as detailed as possible.
Near Miss (Adverse Event was prevented from happening this time)
No Harm or Injury (Event Occurred with No Known Harm)
Low: Minimal Harm (required extra observation or minor treatment)
Moderate: Short Term Harm (Required further treatment or procedure)
Severe: Permanent or Long Term Harm
Death (NOT as a direct result of the incident)
Death (as a direct result of the incident)
Initial Actions Taken at the Scene:
What's been done already?
Should be Empty:
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