Web viewIncident Date: _____ Incident Time: _____Injured Person Name
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Transcript of Web viewIncident Date: _____ Incident Time: _____Injured Person Name
Incident ReportIncident ReportTo be completed by staff within 12 hours of incident/accident
Incident Date: _______________________________ Incident Time: _______________________Injured Person Name: _____________________________________________________________Address: _________________________________________________________________________Phone Numbers: __________________________________________________________________Male/Female: _____________________________ Date of Birth: __________________________
Details of Incident: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Who was injured person? _________________________________________________________Injury Type: _____________________________________________________________________
Does Injury require Hospital/Physician? Yes: ___________________ No: __________________Hospital Name: _____________________________________________________________Address: ___________________________________________________________________Hospital Phone Numbers: _____________________________________________________Injured person/Party Signature/Date: _________________________ /_____________________
Important Notes and Instructions:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prepared By: ______________________________ Date: ________________________________
Name of Approved By: ______________________________ Signature: ____________________
