Incident Report Form

Title Page

Conducted on
Prepared by
Job Title
Supervisor
Urbn Leaf Location
- Bay Park
- La Mesa
- San Ysidro
- Grover Beach
- Seaside
- Vista
Location Where Incident Occured On
- Parking lot
- Lobby
- Budroom
- Back of House
- Break Room
- Restroom
- Other Please Specify:

Incident Reporting Instructions / Guidelines

What Type of Incident Occurred? Please read through the following options and select the type you think best describes the incident.
What is the Difference Between an Accident and an Incident?
The term incident is often interchanged with an accident. Similarly, both events are triggered by unexpected things, however, these two terms are totally different from each other. An incident can be any event that might or might not result in critical or serious damage or injury, while an accident always results in minor or major injuries or illnesses and property damages.
Sentinel events – these are unexpected occurrences that resulted in serious physical or psychological injury or death (e.g. slips, trips and falls, natural disasters, vehicle accidents, disease outbreak, etc.).
Near misses – these are situations where the people involved had no injuries but could have been potentially harmed by the risks detected.
Adverse events – related to medicine, vaccines, and medical devices. These events occur when an act of commission or omission harmed a patient rather than from the existing disease or condition.
No harm events – these are incidents that need to be communicated across an organization to raise awareness of any harm that may happen.

Guidelines for Completing Incident Report's

Accurate
-All data must be clear and specific. Most inaccuracies are due to typos and simple grammar and spelling errors (e.g. incorrect details of names of people involved, date and time of the incident, contact numbers, etc.). Provide more specific details of what you are referring to and avoid any vague statements that may cause confusion. Lastly, always proofread your report before submission to see errors that you might have overlooked.
Factual
-An incident report should be objective and supported by facts. Avoid including emotional, opinionated, and biased statements in the incident report. It should provide both sides of the story and should not favor one side. However, if there’s a need to include statements from witnesses or patients, make sure to quote them.
Complete
-Ensure that all essential questions (what, where, when, why, and how) are covered in the incident report. Record not only the people who were injured and what caused the accident to happen, but also include details such as people who witnessed and reported the incident or those who will conduct an investigation. Anticipate what other significant details will be needed for any future study and investigation.
Graphic
-Photos, diagrams, and illustrations should be included as supporting evidence. Take many photos of the injury, damage, and surrounding environment. This supplements the facts stated and provides more clarity to be easily understood by the recipient.
Valid
-Upon completion, those who are involved in the incident (e.g. victim, witnesses, manager, reporter, etc.) should sign off to testify and validate all the information that was mentioned in the incident report. This confirms that the incident report is truthful and unquestionable.

Incident Details

Person Involved in The Incident

Did this incident result in any injuries?
Name
DOB
Sex
Contact Number/ Email

2. Job Details (if applicable)

Job Title
How long in this occupation
Start time
Hours worked
Shift arrangement
Training/ Qualifications

Incident Details

General Staff Incident <br>
Occurred
Reported
Location of incident
How did the Accident/Near Miss Happen?
Where did the Accident/Near Miss Happen?
Description of any of injury, illness or property damage
Were other people involved in this incident?
Did anyone witness this incident?
Who witnessed this incident ?
Was the person trained for the task they were doing?
Was a significant hazard involved?
How serious could the incident have been?
Take/ upload photo evidence of incident, environment, person(s) involved
Date reported to regulatory authority (leave blank if not required)
Date Incident Report Sent to HR
Incident Report Saved to S Drive

4. Staff Witness Statements (if applicable)

Witness

Name
Job Title
How long in this occupation
Were you working when you witnessed this incident?
Contact
Statement What did you see?
Witness signature

Witness Report (Visitors, 3rd Parties, Vendors, Customers, Security, etc.)

Name
Reason for Visiting Urbn Leaf
What were you doing when you witnessed this incident?
Contact Information: Name: Phone Number: Email Address:
Statement What did you see?
By signing this witness statement, you acknowledge that Urbn Leaf may contact you via the information you provided and/or provide your contact information to other required parties.
Witness signature
Date & Time

Workplace Violence Related Incident

Was this an incident involving violence or the potential for violence?
Type of incident (check all that apply)
Grabbed Pushed Slapped
Kicked Scratched Hit with fist
Hit with object Bitten Stabbed (or attempted)
Shot (or attempted) Sexually assaulted Assaulted with weapon
Threatened with weapon Verbally harassed Verbally threatened
Bomb threat Animal attack Robbery Arson
Vandalism (employer’s property) Vandalism (own property) Other
What type of weapon was used? How was the weapon obtained?
Were security personnel on duty at the time of the assault? If yes, was security notified?
Did security respond? When?
Who threatened or assaulted you?
Client/customer Patient
Family/friend of client or patient
Co-worker Supervisor/manager
Stranger Animal
Friend Family Member Spouse or partner Former spouse or partner
Other - Please Explain
Robber/burglar
Were any threats made before the incident occurred? If yes, did you ever report to your supervisor or manager that you were threatened, harassed or suspicious that the attacker may become violent?
Has this type of incident occurred before at the workplace?
What do you think were the main factors that contributed to the incident?
What could have prevented or at least minimized the damage caused by this incident?

Conclusion

Additional observations and comments (If Applicable)
Name and signature of reporting person

Post-Incident Response

Post Incident Supervisor Follow Up

Is there an Action Plan to prevent the same/ similar incident from reoccuring?
Summary of Action Plan:
If no, when will your Action Plan be completed?
Has this Plan been implemented ?
If yes, when? If no, when is the expected implementation date?
What Locations will utilize this plan?
- Bay Park
- La Mesa
- San Ysidro
- Grover Beach
- Seaside
- Vista

Follow Up Questions For Individual Who Reported the Incident

Has HR followed up with you regarding this incident?
Has Management followed up with you regarding this incident?
Was this incident handled in an efficient and professional manner?
Do you have any additional questions regarding this incident?
Did you miss work as a result of the incident?
Did you apply for workers’ compensation?
Was the incident reported to a supervisor or manager?
Was a police report filed?
Was immediate counseling provided to affected workers and witnesses who desired it?
Was critical incident debriefing provided to all affected staff who desired it?
Was post-trauma (follow-up) counseling provided to all affected staff who desired it?
Was all counseling provided by a professional counselor?
Was the counseling effective?
Was the victim advised about legal rights?