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Incident Report Templates

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Incident Report Templates Powered By Docstoc
					This document is an example of an incident report template. This document is a blank
form, and should be filled out by the person reporting the incident. This form includes
sections to be filled out, such as what was taking place when the incident occurred; who
witnessed the incident, and a description of who the perpetrator is. This document in its
draft form contains numerous of the standard clauses commonly used in these types of
forms; however, additional language can easily be added. This document can be used
by small businesses and is useful to document incidents that occur within the company.
          INCIDENT REPORT
             TEMPLATE



                       (Insert Year)




© Copyright 2013 Docstoc Inc.          2
    Introduction:


Complete a separate form for each incident, within three (3) days of the incident occurring.

Remember that failure to report an incident could result in someone else being put at risk in the
future.




This form should be used for each occasion of:


       Aggressive behavior
       Verbal abuse
       Destruction of equipment or property (or threats of)
       Physical assault (or threats of)




    © Copyright 2013 Docstoc Inc.                                                           3
Name of person completing the form:
Last Name: _____________________________ First Name: __________________________
Position title: ___________________________
Date of incident: _________________________
Time: _______________ [Circle one] AM / PM
Location of incident:
_____________________________________
_____________________________________
_____________________________________



What was taking place when the incident occurred?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________



Other persons present at the time:

Last Name 1: ____________________________ First Name 1:_________________________
Last Name 2: ____________________________ First Name 2:_________________________
Last Name 3: ____________________________ First Name 3:_________________________
Last Name 4: ____________________________ First Name 4:_________________________




Name of perpetrator(s) if known, or description if unknown:

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________



    © Copyright 2013 Docstoc Inc.                                           4
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________




Was the perpetrator(s):
Y N
                 A young person who is known to the service (i.e. client)
                 A young person unknown to the service
                 A relative of a young person
                 A friend of a young person
                 A partner or ex-partner of a client
                 A volunteer
                 A staff member
                 A person unknown to any staff members, volunteers or young people
                 Other _______________________________________________________




What happened:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________


    © Copyright 2013 Docstoc Inc.                                                    5
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________________
Who was the aggression aimed at:
             Persons unknown to the service (e.g. passerby)
             Young person/s at the service
             Volunteer
             Staff member/s
             Property
             Other _________________________

Were any injuries sustained?                       No

If yes, Name of injured person:

Last Name 1: ____________________________ First Name 1:_________________________
Last Name 2: ____________________________ First Name 2:_________________________
Last Name 3: ____________________________ First Name 3:_________________________
Last Name 4: ____________________________ First Name 4:_________________________




    © Copyright 2013 Docstoc Inc.                                           6
Details of injuries:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________

First aid or treatment:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________

Was any property or equipment damaged

If yes, details of damage:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________

What was the cause of the incident?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________



   © Copyright 2013 Docstoc Inc.                                        7
__________________________________________________________________________________
________________________________________


With hindsight, what warning signs were evident prior to the incident?

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________



What action did staff or volunteers take, if any, to try and address the situation prior to the incident
occurring?

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________

What action did staff or volunteers take, if any, to try and address the situation during or after the
incident?

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________




    © Copyright 2013 Docstoc Inc.                                                             8
Has the incident been reported to the appropriate supervisor?


Have staff and volunteers been provided with an opportunity to debrief and discuss the issue?



Follow up action required:




Signed: _______________________________                  Date: _________________________




    © Copyright 2013 Docstoc Inc.                                                         9

				
DOCUMENT INFO
Description: This document is an example of an incident report template. This document is a blank form, and should be filled out by the person reporting the incident. This form includes sections to be filled out, such as what was taking place when the incident occurred; who witnessed the incident, and a description of who the perpetrator is. This document in its draft form contains numerous of the standard clauses commonly used in these types of forms; however, additional language can easily be added. This document can be used by small businesses and is useful to document incidents that occur within the company.
This document is also part of a package Small Claim Starter Kit 9 Documents Included