Incident Report Templates

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This is an example of incident report templates. This document is useful for incident report.

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Shared by: Crisologa Lapuz
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Incident report template Complete a separate form for each incident, within 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 behaviour Verbal abuse Destruction of equipment or property (or threats of) Physical assault (or threats of) Name of person completing the form: ______________________________________ Position title:__________________________________________________________ Date of incident : _________________ Time: _______________ am/pm Location of incident: _____________________________________ What was taking place when the incident occurred? __________________________ ____________________________________________________________________ Other persons present at the time:________________________________________ Name of perpetrator if known, or description if unknown: ______________________ ____________________________________________________________________ Was the perpetrator  A young person who is known to the service (ie 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 _______________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Who was the aggression aimed at  Persons unknown to the service (eg passer by)  Young person/s at the service  Volunteer  Staff member/s  Property  Other _________________________ Were any injuries sustained? Yes No If yes, Name of injured person: __________________________________________ Details of injuries: _____________________________________________________ First aid or treatment: __________________________________________________ ____________________________________________________________________ Was any property or equipment damaged Yes No If yes, details of damage: ____________________________________________ What was the cause of the incident? ______________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 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? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Yes No Has the incident been reported to the appropriate supervisor? Have staff and volunteers been provided with an opportunity to debrief and discuss the issue? Yes No Follow up action required: _______________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Signed: _______________________________ Date: _______________

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