Incident form

Incident report form

A form for recording a patient safety, staff safety or environmental incident: what happened, the harm, what was done at once, and whether the person affected has been told.

Fill it in online - free, no account needed. 13 questions.

What it is for

Record the facts while they are fresh, in the order an investigator will need them.

The full question list

1. When and where

  1. Date and time of the incident *
  2. Where it happened (ward, room or area) *

2. What happened (do not name patients)

  1. Type of incident *
  2. Who was affected *
  3. Level of harm *
  4. What happened, in the order it happened *
  5. What was done straight away *
  6. Who saw it (roles, not names of patients)

3. After the incident

  1. The person affected, or someone acting for them, has been told what happened *
  2. Whether this must be notified to the regulator has been considered *
  3. The manager in charge has been informed *

4. Reported by

  1. Your role *
  2. Reported by *

References

How the score works

The score is the share of scored questions that pass. N/A is left out of the score; text, dates and signatures are recorded but not scored. A completed template is a record of what you checked; it is not an inspection by a regulator or an accreditation body.