Accident & Incident Report

• Document No.

• Conducted on

  Date

• Prepared by

• Location
  Address

OVERVIEW

• The name of the individual this report refers to

• The name of Staff completing the report

• The name of Line Manager

• Date and time of event

  Date

• Time reporting this event

  Date

• Type of eventuality

  Accident

  Incident

• Category type

  Select Abuse Arson Anti- Social Behaviour (ASB) Assault Choking Death Fire Medication Error Missing Person Personal Injury Property Damage Road Traffic Accident (RTA) Seizure Self- Harm Slip, Trip and Falls Substance Misuse (accidental) Substance Abuse Theft Verbal Aggression Violence Sexual Abuse

  • Abuse
  • Arson
  • Anti- Social Behaviour (ASB)
  • Assault
  • Choking
  • Death
  • Fire
  • Medication Error
  • Missing Person
  • Personal Injury
  • Property Damage
  • Road Traffic Accident (RTA)
  • Seizure
  • Self- Harm
  • Slip, Trip and Falls
  • Substance Misuse (accidental)
  • Substance Abuse
  • Theft
  • Verbal Aggression
  • Violence
  • Sexual Abuse

• Location of event (Specify site location)

• Were there any witness(es)

  Yes

  No

  N/A

• Number of witness(es)

• Name of any witnesses

SECTION 1-DETAILS OF INJURY, (IF APPLICABLE)

• Describe injury

• Detail any first-aid or medical treatment administered. (Provide Names)

• Who was Injured?

  Staff

  Visitors

  Volunteers

  N/A/No one

  Member

SECTION 2-DETAILS OF INCIDENT OR ACCIDENT, (IF APPLICABLE)

• Describe the incident or accident

• Detail any first-aid or medical treatment administered. (Provide Names)

SECTION 3- DETAILS OF PROPERTY DAMAGE, IF APPLICABLE

• Property Damage:

  None

  Minor

  Serious

  Major

• Photo of Damage.

  Media

• Detailed description of incident. (Include environmental conditions at time of incident)

ANALYSIS

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Select Certain Very Likely Likely Unlikely Very Unlikely Impossible

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Impossible

REPORTING

• Safeguarding Intervention required?

  Yes

  No

• Does the Local Authority need to be informed?

  Yes

  No

• Does CQC need to be informed?

  Yes

  No

• Who is the responsible person who will raise the above? ( for example, Line Manager)

• If you have had to do one of the above, please state time/date

  Date

• Do we need to report this event to RIDDOR?

  Yes

  No

• Does a risk assessment need to be reviewed or put in place?

  Yes

  No

• Is there any identified training required?

  Yes

  No

• Do we require an investigation?

  Yes

  No

• Reportable to Senior Leadership Management and Health and Safety Committee?

  Yes

  No

• Please clearly outline all of the actions required for this particular event.