Incident Report

The completion and execution of this Personal Injury Report does not in any way constitute an admission of liability in respect of the alleged incident the subject of the Report and is without prejudice.

The parish is to retain the original of this form in a register of incidents.

DO NOT give a copy of this Incident Report to the affected person.

WHAT, WHEN AND WHERE

Incident Date *

Type of Incident *

Specific incident location *

Day of the week *

Time of day *

If outside a building, describe the weather conditions

If inside a building, describe the lighting level

AFFECTED PERSON

Full name of affected person *

Address of affected person

Phone number of affected person

Date of Birth of affected person

REPORTED

This incident was reported by *

This incident was reported to *

Position of person the incident was reported to *

Date incident was reported *

Time incident was reported *

TREATMENT INFORMATION

Was First Aid administered? *

Yes

If First Aid was administered, please give details

Was a Doctor consulted *

Yes

If a Doctor was consulted, please give details

Was an ambulance called *

Yes

If an ambulance was called, please give details

DETAILS OF ALLEGED INJURY

Please provide details of alleged injury *

DESCRIPTION OF THE INCIDENT

Please describe the incident as it happened, step by step -do not offer opinions on why certain things did or did not happen *

WITNESSES

Please provide the name and contact number of any witnesses to the incident, along with details of the relationship between the witnesses and the affected person *

ACTION TAKEN

What action has been taken?

PERSON COMPLETING FORM

Name of person completing the form *

Position of person completing the form *

Date *

The information in this form is correct to the best of my knowledge. *

Yes