INCIDENT REPORT FORM
Name of person completing this form
Email address of person completing this form
Date and Time of Incident
Location of Event
Describe what was being done at the time of the incident (including any equipment or tools being used)
What was the cause of the incident?
What injury occurred?
What treatment was administered, and where was it administered. Enter multiple treatments and locations if applicable.
Type of incident
Death of a person
Serious injury or illness (Requires immediate treatment in hospital or ambulance)
A dangerous incident
A minor incident
Did this incident involve exposure to dangerous substances or human fluids other than the person who received the injury/illness? If so please explain.
Who at Sympact has been notified of this incident?
In your opinion, how could this incident have been avoided?