Incident report form
====================

Incident report: [ORGANIZATION NAME]

Report number: [NUMBER]

About the incident

- Date: [DATE]
- Time: [TIME]
- Location (be specific): [LOCATION]
- Activity or event: [ACTIVITY]
- Type (tick all that apply): [ ] Injury or illness [ ] Near miss [ ] Property damage, loss or theft [ ] Behavior or complaint [ ] Safeguarding concern [ ] Other: [DESCRIBE]

People involved

| Name | Role (participant, volunteer, employee, visitor) | Age if under 18 | Contact details | Injured? |
|---|---|---|---|---|
| [NAME] | [ROLE] | [AGE] | [PHONE OR EMAIL] | [YES OR NO] |
| [NAME] | [ROLE] | [AGE] | [PHONE OR EMAIL] | [YES OR NO] |

Witnesses

| Name | Contact details | Statement attached? |
|---|---|---|
| [NAME] | [PHONE OR EMAIL] | [YES OR NO] |
| [NAME] | [PHONE OR EMAIL] | [YES OR NO] |

What happened

Describe what happened in order, in plain facts. What were people doing just before? What did you see and hear?

[DESCRIPTION]

Injuries and first aid

- Description of any injury or illness: [DETAILS]
- First aid given, and by whom: [DETAILS]
- Was 911 called? [YES OR NO]. Taken to hospital? [YES OR NO, AND WHERE]
- Parent, guardian or emergency contact told? [YES OR NO, WHO, AND WHEN]

Property

- What was damaged, lost or stolen: [DETAILS]
- Estimated value or repair cost: $[AMOUNT]
- Police report number, if any: [NUMBER]

Immediate actions

What was done straight away to make the situation safe?

[ACTIONS]

Who has been notified

| Who | Notified by | Date and time |
|---|---|---|
| Supervisor or program lead | [NAME] | [DATE AND TIME] |
| Safeguarding lead (if a safeguarding concern) | [NAME] | [DATE AND TIME] |
| Child protection or adult protective services (if required) | [NAME] | [DATE AND TIME] |
| Insurer | [NAME] | [DATE AND TIME] |
| OSHA (if a serious employee injury) | [NAME] | [DATE AND TIME] |
| Board chair or executive director | [NAME] | [DATE AND TIME] |

Follow-up

- What caused it, as far as we can tell: [CAUSE]
- What we'll change to stop it happening again: [ACTIONS]
- Who will do it, and by when: [NAME AND DATE]
- Follow-up with the people involved: [DETAILS]

Signatures

Report completed by: [NAME AND ROLE]

Signature: [SIGNATURE]

Date: [DATE]

Reviewed by: [NAME AND ROLE]

Signature: [SIGNATURE]

Date: [DATE]