Incident Report Form (Example)
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1
2Incident report form (example)
INJURED PERSONS DETAILS
Name
Address
Phone number
INJURY DETAILS
Event
Attending:
Location of
Event:
Date of Incident:
/_
/_
Nature and extent of injury
Time: Medical
□
□
Trunk
□
Multiple
Treatment required:
Head
□
□
Arm
□
General
Eyes
Part of body injured
□
□
Leg
□
Unspecified
Neck
□
□
Laceration
□
Burn
Sprain
□
□
Concussion
□
Superficial
Fracture
Nature of injury
□
□
Dislocation
□
Amputation
Multiple
□
□
Other
Contusion
□
Flying object □
Manual handling
□
Electricity
Type of incident
□
□
Poisons
□
Fall
Struck by
□
□
Temperature
□
Other
Caught in
Events Management Guide – Version 1.0
36
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Parent category: Business