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 DetailsDate of incident/accident:* Date Format: 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 occurredDid the person go to hospital?YesNoWho 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?YesNoWas follow up treatment recommended, if yes, please give details:Was there any delay between accident and treatment?YesNoDetails of treatment delay if any:WitnessesWere there any witnesses?YesNoDetails of witnesses (names, and where applicable addresses)Others InvolvedWere there any other persons injured?YesNoDetails of other persons injured (names, and where applicable addresses)Property DamageDid any property get damaged during the incident/accident?YesNoDetails 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:YesNoFamily/next of kin informed:YesNoCase manager informed:YesNoHR/H&S Informed (Within 48 hrs):YesNoCIW informed:YesNoName of person completing form:Date (person completing form): Date Format: DD slash MM slash YYYY Name of line manager:Date (line manager): Date Format: DD slash MM slash YYYY Registered Manager:Date (registered manager): Date Format: DD slash MM slash YYYY Further actions:PhoneThis field is for validation purposes and should be left unchanged.
