Incident report form (example template)

A single form for accidents, incidents and near misses, with a built-in notifications checklist so no duty gets missed.

Prints on one or two A4 pages

Use with care: this is a generic example layout for training and discussion. Always use your own organisation's approved forms where they exist, and follow local policy.

Person(s) involved
Status (person supported / staff / visitor)
Date and time of incident
Location
Witnesses
Reported by

1. What happened (facts only — what you saw, heard and did)

2. Injuries (describe; complete a body map for any mark)

3. Immediate actions taken (first aid, clinical advice, environment made safe)

4. Notifications checklist

Manager / on-call informed	Yes / No — time:
Family / representative informed	Yes / No / NA — time:
GP / 111 / 999 involved	Yes / No — detail:
CQC notification required?	Yes / No — sent (date/time):
RIDDOR reportable?	Yes / No — reported (date):
Safeguarding referral required?	Yes / No — made (date):
Duty of candour applies?	Yes / No — conversation (date):

5. Follow-up: cause, learning and actions (owner and date for each)

Completed by (signature, date)
Manager review (signature, date)

Generic example template from UK Care Reference — educational use only. Printed __/__/____