INCIDENT REPORTING FORM Part 1

1
DETAILS OF PERSON WHO REPORTED THE INCIDENT
First Name
Last Name
2
Your Job Title
3
Date of Incident
Date
Year
Month
Day
4
Time of Incident
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
5
Manager Incident Reported to
First Name
Last Name
6
How were you involved in the incident?
Present at scene of incident
Unobserved Incident
Abuse by Phone
Abuse by other communication
7
DETAILS OF PERSON INVOLVEDEnter details of whom the incident occurred, or for Violence/Abuse Incidents enter details of the ‘VICTIM’ (or for V/A details of property if not a person)
First name and surname:
Known as:
Job Title (if employee):
Please Select
Please Select
Male
Female
Male / Female:
Ethnic Origin:
Date of Birth:
Please Select
Please Select
Service User
Employee
Employee – Agency
Shared Lives Carer
Contractor
Reablement
Relative
Property / Equipment / Fixtures
Personal items
Student
Visitor
Volunteer
Role / Reason in Unit:
8
DETAILS OF PERSON INVOLVED(For Violence/Abuse Incidents ONLY) Enter details of the Person who ‘CAUSED’ the Incident
First name and surname:
Known as:
Job Title (if employee):
Please Select
Please Select
Male
Female
Male / Female:
Ethnic Origin:
Please Select
Please Select
Service User
Employee
Employee – Agency
Shared Lives Carer
Contractor
Relative
Reablement
Student
Member of Public
Visitor
Volunteer
Role / Reason in Unit:
If V/A behaviour has been repetitive, enter number of incidents that have occurred during the day:
9
If Employee incident do you agree to have details disclosed to a H&S Rep / Auditor?
YESNO
10
LOCATION (Where did the incident take place?) If in Service User’s home – enter address details
Room / Area:
Exact location:
11
FACTUAL DESCRIPTION OF INCIDENT (ONLY write what happened – i.e. what you saw / found at the scene of the incident)
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Large
Normal
Small
Ok
Ok
12
WHY DO YOU THINK THIS MIGHT HAVE HAPPENED? (Triggers / antecedents) - Optional
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Large
Normal
Small
Ok
Ok
13
IMMEDIATE ACTION(What did you do and who did you tell?)
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Large
Normal
Small
Ok
Ok
Should be Empty: