Incident report form

Incident report form

  • See attached document below for downloadable word document version of this form
  • This is the detailed incident report form to be used by delivery partners and is designed to get detailed information relating to incidents.

Incident Report Q&A Form

Name of person reporting incident:

 

Date of incident:

 

Date of report:

 

Your email:

 

Mobile:

 

Landline:

 

Location of incident (town, city):

 

LDP:

 

RDP:

 



ABOUT THE INCIDENT

·       What is the criticality Level of the incident (where 4 is the least critical and 1 is the most)?

 

(See incident categorisation for details)

·     What phase of the programme are you in?

 

(E.g. full-time residential, social action project, etc.)

·    Where and when did the incident take place?

 

(Physical environment e.g. during a flying fox activity, or in the residential building hallway, etc.)

·       Who are the parties involved?

 

 

·       Who witnessed the incident?

 

 

·   What happened in the lead-up to the incident?

 

(Give details on any factors that may have contributed e.g. past arguments between two YP’s, detail any pre-existing conditions or situations that may have affected the persons involved)

 

·  Describe the incident itself – what happened & who was involved?

 

(Provide as much detail as possible)

·       Briefly what is the current situation at the time of writing?

 

 

 

·       Are any charges being brought?

 

 

HEALTH & SAFETY

·   Have the appropriate authorities been contacted? E.g. police, ambulance, fire services

 

 

·       Are any other people at risk?

Have they been removed from that risk?

 

 

·      What is the current condition and location of the individual(s) affected?

 

 

·   Is there a need for counselling to be provided, does the RDP have provision for counselling in place?

 

 

·      What is the ongoing plan to keep relevant stakeholders informed (i.e. young people / parents, where counselling may be necessary)

 

 

EFFECT ON PROGRAMME

·       Is there any disruption to the programme?

 

 

·   Does the programme need to be shut down?

 

 

·    Have parents / guardians of those affected been contacted?

 

 

·       What provisions have been made for the safe return of young people to their homes?

 

 

MEDIA IMPACT & ONGOING COMMS

·   Have YP been asked to refrain from communicating about the incident by phone or social media?

 

 

·      Has there been any comment on social media? (Include links or names)

 

 

·       Has there been any media interest?

 

 

·   Please provide contact details for the person responsible for social media in your organization

 

 

·    Please provide contact details for the person responsible for PR in your organization

 

 

ADDITIONAL INFORMATION

(Please provide any further details you may have relating to the incident or those involved that does not apply to any of the questions above)