Staff - Incident Report
Please fill out the form carefully
Staff Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident.
*
What type of incident are you reporting?
*
Wound (abrasion, lacerations, punctures, etc.)
Musculoskeletal (rolled ankles, muscle sprains, fractures, dislocations, etc.)
Environmental (Cold/heat illness, dehydration, altitude, etc.)
Medical (missed medication, diabetes, heart issues, lung issues, etc.)
Behavioral (mental health, fights, etc.)
Was emergency services contacted?
*
Yes
No
Provide information from emergency services.
Name of person involved.
*
First Name
Last Name
Name of person involved.
First Name
Last Name
Name of witness.
First Name
Last Name
Name of witness.
First Name
Last Name
Detailed description of what happened.
*
Description of the response taken.
*
Additional information.
Did you supply care?
*
Yes
No
Did you use the first aid kit?
*
Yes
No
What was used from the first aid kit?
Restock used items please.
Who does New Treks upper management need to contact as a follow up?
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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