Incident report

Fill this in as soon as you can after the incident, while it’s fresh.

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Reported by*

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Date of incident*

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Time*

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Location*

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Type

A Injury B Near miss C Damage D Behaviour E Other

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What happened?*

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People involved

Person 1

Name*

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Role

A Staff B Member C Visitor D Other

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Was anyone injured?

A Yes B No

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Injury and treatment given

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Witnesses (names and contact)

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Photo

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Reporter’s signature*

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