ACCIDENT, INCIDENT OR NEAR MISS REPORTING FORM

This record sheet is to record any serious incidents. It should include any incidents that results in any loss, damage or injury to any property, person or company. For example – falls, medical emergencies (asthmatic attacks, autonomic dysreflexia, etc.), major behavioural outbursts.

NB – Any accidents to staff or clients are also to be recorded in the existing Accident Book.

Name of Reporter Name of Reporter First Last
Date report completed Date report completed / DD / MM YYYY
Address Address
Street Address Address Line 2 City County Postcode Country
Phone
Email
Name of Person Involved (if different to above) Name of Person Involved (if different to above) First Last
Address Address
Street Address Address Line 2 City County Postcode Country
Section Break

This is the description of your section break.
Client Name
(use abbreviation of first letter of first name and first 3 of surname only eg, SBar)
Date of incident Date of incident / DD / MM YYYY
Time of incident Time of incident : HH MM AM/PM
Location of Incident
Type Of Incident
Names of persons involved and relation to Client / person involved inc any witnesses and contact details:
Describe the details of the accident, incident or near miss: (Facts only to be recorded – not opinion
Action taken at the time:
(please remember to complete the accident book for all accidents and injuries)
How harmful was this incident ?
Actual Impact
How harmful was this incident ?
Likelihood of Reoccurrence

ACCIDENT, INCIDENT OR NEAR MISS REPORTING FORM

ACCIDENT, INCIDENT OR NEAR MISS REPORTING FORM

Section Break