Accident & Incident Form

Name of person(s) involved in accident / incident

Name of witness(es)

Role of person involved in accident / incident

i.e carer, service user etc

Time and date of accident/incident

Date

Time

How did the accident / incident happen?

Details of apparent injuries

Supporting documents

Click or drag a file to this area to upload.

Reason given for cause of accident / incident ?

Should the person have been on the premises?

Were they carrying out normal duties?

Were they acting in accordance with policy, procedure and training?

Was personal protective equipment provided for the work?

Was the personal protective equipment being worn?

If the answer to any of these questions is 'no', provide full details

Care Manager Investigation Notes

Care Manager Recommendations

Name

Signature