Incident Report Template
Injury Incident Report FormIncident Report TemplatePrepared By: ______________________________ Date: ________________________________To be completed by staff within 12 hours of incident/accidentIncident Date: _______________________________ Incident Time: ________________________________Injured Person Name: ______________________________________________________________________Address: __________________________________________________________________________________Phone Numbers: ___________________________________________________________________________Male/Female: ________________________________ Date of Birth: ________________________________Does Injury require Hospital/Physician? Yes: _______________________ No: _______________________Hospital Name: _____________________________________________________________________Address: ___________________________________________________________________________Hospital Phone Numbers: _____________________________________________________________Injured person/Party Signature/Date: _________________________ /______________________________Details of Incident: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Who was injured person? __________________________________________________________________Injury Type: _______________________________________________________________________________Important Notes and Instructions: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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