Incident Report

Date Incident Occurred*

Use today's date if unknown.

Time Incident Occurred*

Use reporting time if unknown.

: HH

MM

Employee Reporting Incident*

First Last

Name and Phone Number of Involved Party or Parties (if known):

Name and Phone Number of Witness(es):

Did incident result in illness or bodily injury to any staff?*

Has a workmans compensation claim been made to report incident?*

Details of workmans compensation claim:

Include date/time of notification, case number, and any additional pertinent information.

Did incident involve bodily injury or illness to a non-employee of Code One (i.e. customer or bystander)?*

Was first aid rendered to the ill or injured party?*

Describe care that was rendered and who provided care:

Were emergency services (police, fire, EMS) notified of this incident?*

Details of emergency services:

Include date/time of notification, case number, responding agencies, and disposition (i.e. patient transported to Memorial Hospital).

Was the ill or injured party or parties advised to seek follow-up care at a medical facility?*

Details of referral:

Please indicate any details about instructions given to party or parties regarding follow-up care, how many times they were advised to seek care, and if they planned to seek follow-up care or refused.

Did incident result in damage to property?*

Property damage details:

Describe damaged property, owner of the property (if known), and estimated cost to repair or replace:

Incident Report

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