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    Patient Incident Report

    Uploaded by

    TN Sanjay
    This patient incident report form is used to document any accidents, injuries, medical issues, criminal activity, traffic incidents, or behavioral issues involving students. It requests information about the date and time of the incident, location, description of what happened, any injuries sustained, witnesses, whether police or medical services were involved, and the person filing the report. The form stresses that reports should be completed within 24 hours of an incident whenever possible.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Patient Incident Report

    Uploaded by

    TN Sanjay
    54 views2 pages
    This patient incident report form is used to document any accidents, injuries, medical issues, criminal activity, traffic incidents, or behavioral issues involving students. It requests information about the date and time of the incident, location, description of what happened, any injuries sustained, witnesses, whether police or medical services were involved, and the person filing the report. The form stresses that reports should be completed within 24 hours of an incident whenever possible.

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    © © All Rights Reserved

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    This patient incident report form is used to document any accidents, injuries, medical issues, criminal activity, traffic incidents, or behavioral issues involving students. It requests information about the date and time of the incident, location, description of what happened, any injuries sustained, witnesses, whether police or medical services were involved, and the person filing the report. The form stresses that reports should be completed within 24 hours of an incident whenever possible.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    54 views2 pages

    Patient Incident Report

    Uploaded by

    TN Sanjay
    This patient incident report form is used to document any accidents, injuries, medical issues, criminal activity, traffic incidents, or behavioral issues involving students. It requests information about the date and time of the incident, location, description of what happened, any injuries sustained, witnesses, whether police or medical services were involved, and the person filing the report. The form stresses that reports should be completed within 24 hours of an incident whenever possible.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    PATIENT INCIDENT REPORT FORM

    Use this form to report accidents, injuries, medical situations, criminal activities, traffic
    incidents, or student behavior incidents. If possible, a report should be completed within
    24 hours of the event.

    Date of Report: _________________, 20____

    PERSON INVOLVED

    Full Name: _________________ Address: __________________________________

    Identification: ☐ Driver’s License No. _____________ ☐ Passport No. _____________


    ☐ Other: __________________________

    Phone: (____) ____-_____ E-Mail: _________________

    THE INCIDENT

    Date of Incident: _________________, 20____ Time: ____:_____ ☐ AM ☐ PM

    Location: __________________________________

    Describe the Incident: ____________________________________________________


    ______________________________________________________________________
    ______________________________________________________________________

    INJURIES

    Was anyone injured? ☐ Yes ☐ No

    If yes, describe the injuries: _______________________________________________


    ______________________________________________________________________
    ______________________________________________________________________

    WITNESSES

    Were there witnesses to the incident? ☐ Yes ☐ No

    If yes, enter the witnesses’ names and contact info: ____________________________


    ______________________________________________________________________
    ______________________________________________________________________

    Page 1 of 2
    POLICE / MEDICAL SERVICES

    Police Notified? ☐ Yes ☐ No If yes, was a report filed? ☐ Yes ☐ No

    Was medical treatment provided? ☐ Yes ☐ No ☐ Refused

    If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other: _______

    PERSON FILING REPORT

    Signature: ________________________ Date: _____________

    Print Name: ________________________

    OFFICE USE ONLY

    Report received by: _________________ Date: _________________, 20____

    Follow-up action taken: ___________________________________________________


    ______________________________________________________________________
    ______________________________________________________________________

    Page 2 of 2

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