Incident Report form — Tribe Aged Care Central Coast and Wollongong

Aged Care Services throughout Central Coast and Wollongong

To be completed within 12 hours of the incident/accident occurring by witnesses or people involved in incident.

Date of incident

Time of incident

Injured person’s name

Incident location

Name of person reporting the incident

First Name

Last Name

Phone

(###)

###

####

Email

Date of report

MM

DD

YYYY

Witness details

Name of witness

Phone

(###)

###

####

Email

Witness’ description of the incident

Description of the Incident (staff)

Identify who provided information (for future investigation)

Description of injuries or impact on person (if applicable)

Actions taken by our organisation (e.g. first aid, ambulance called, support to person)