Incident Report Writing - Nursing Assessment
Incident Report Form
1. Workplace details
- Location
- Director: Contact phone
- Setting:
2. Incident details
- Day-Date: Time:
- Report completed by:
3. Type of incident (indicate which is applicable)
- Personal injury Staff Customer Child
- Name of a person injured:
- Part of Body Injured (if relevant): Left chin
- Nature of injury sustained: Abrasions, scrapes Bite Broken bone/fracture Bruise Burn Concussion Cut Rash Sprain Swelling Other (please specify)
- Approximate size/colour of injury:
- Lotus Compassionate Care Incident Report Form V1.0 – Produced 7 November 2019 Page 1 of 3 © Commonwealth of Australia 2012, Licensed under Creative Commons Attribution-ShareAlike 3.0 Australia License
- Damage to goods (please specify):
- Assault Staff Customer Other (please specify):
- Vandalism Robbery/break-in (also complete security incident report form)
- Equipment failure/damage (please specify):
4. Response to an incident (indicate which is applicable)
- First aid treatment administered (please specify what/by whom etc):
- The medical treatment administered (please specify where/by whom etc):
- Assistance sought: (please specify type) Ambulance Police Counsellor
- Equipment shut down (please specify what/when etc):
- Centre closed (please specify exact time):
- Lotus Compassionate Care Incident Report Form V1.0 – Produced 7 November 2019 Page 2 of 3 © Commonwealth of Australia 2012, Licensed under Creative Commons Attribution-ShareAlike 3.0 Australia License
- Repair person contacted (please specify whom):
