⚠️Staff Incident Report Form

This Staff Incident Report Form is designed to record details of any workplace incident involving a staff member, whether related to health and safety, conduct, safeguarding, or other concerns. Completing this form promptly and thoroughly ensures that appropriate actions can be taken to safeguard staff, service users, and the organisation, and to support learning and improvement.

👤Section 1: Staff Member Details

Full Name of Staff Member Involved

Job Title/Role

Name of Manager/Supervisor

📅Section 2: Incident Details

Date of Incident

Time of Incident

Location of Incident

Type of Incident (please briefly describe)

📝Section 3: Description of the Incident

What occurred?

Who was Involved?

Include names and roles

Were their any witnessses present?

What actions were taken at the time?

🚑Section 4: Outcome and Immediate Actions

Injuries and/or harm caused?

If yes, please describe:

Was medical attention required?

If yes, what was provided and by whom?

Were any immediate actions taken to make the situation safe?

🔔Section 5: Reporting and Follow-Up

Who was the incident reported to (name and role)?

Date and time reported

Is further investigation required?

If yes, please provide details or recommendations:

✍️Section 6: Signature

Signature

Clear

Date