MD Korea Incident report

• Title

• Location

• Conducted on

  Date

• Prepared by

SECTION I

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

PERSON(S) INVOLOVED

• Name (Person 1):

• Age;

• Job Title:

• Time on job: (Yrs & Mos)

• Medication prescribed? If yes list medications.

  Yes

  No

  N/A

NATURE OF INJURY

• Detailed deskription of Incident

• Supporting Photo

  Media

• Describe injury. (If applicable)

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

• 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?

  Remote

  Improbable

  Probable

• Select date

  Date

• Signature

  Sign