Service Users and StaffFull name of service user / staff sustaining injury:* Date of Birth: Home Address: Street Address Address Line 2 Town or City Postcode Telephone Number: Accident DetailsWas the Accident/Near Miss a result of challenging behaviour shown by the service user?* Yes No Have you completed the ABC Behaviour Chart form?* Yes No Date of incident/accident:* DD slash MM slash YYYY Time of incident/accident: Location of incident/accident: Incident/Accident Details: How it occurred, when, why, who, what:Description of injury sustained by each person:Treatment or medication given:How did the injury occur?Please tick the boxes that apply. Injured while handling, lifting or carrying Slipped, tripped or fell on the same level Result of service user interaction Hit by moving, flying or falling object Contact with moving machinery Contact with electricity Other reason (please specify below) Other reason how the injury occurred Did the person go to hospital? Yes No Who supported the person at hospital? Details of what happened at hospital:Treated by: (please indicate designation e.g. nurse, paramedic etc) their names: Kept in hospital more than 24 hours? Yes No Was follow up treatment recommended, if yes, please give details:Was there any delay between accident and treatment? Yes No Details of treatment delay if any:WitnessesWere there any witnesses? Yes No Details of witnesses (names, and where applicable addresses)Others InvolvedWere there any other persons injured? Yes No Details of other persons injured (names, and where applicable addresses)Property DamageDid any property get damaged during the incident/accident? Yes No Details of property damage:Further ActionsHow could this incident/accident be prevented?Has the cause of the incident/accident been rectified?Are there any Health & Safety concerns to address?Line manager informed: Yes No Family/next of kin informed: Yes No Case manager informed: Yes No HR/H&S Informed (Within 48 hrs): Yes No CIW informed: Yes No Name of person completing form: Date (person completing form): DD slash MM slash YYYY Name of line manager: Date (line manager): DD slash MM slash YYYY Further actions:EmailThis field is for validation purposes and should be left unchanged.
