Adverse Incident IR1 Report Form
Ref No: Insert Reference
Number.
Details of Incident
Date: Click here to enter a date.
Click here to enter time.
Time:
Enter Incident Number
Incident No:
Location
Premises No/Name:
Town:
Premises name/No
Town
Street
Street:
County:
County
Postcode:
Postcode
Type of Incident (Please tick one or more as appropriate)
☐
☐
☐
☐
☐
☐
☐
☐
Fire
Near Miss
Patient/Manual Handling
Clinical Risk
Vehicle
Welfare
Frequent/Hoax Caller
Finance
☐
☐
☐
☐
☐
☐
☐
☐
Equipment
Assault
Security
Violent Incident
Telecommunications/Media
Inter-Agency Issue
Control of Infection
Information Governance
☐
☐
☐
☐
☐
☐
☐
☐
Personal Accident
Ill Health
Estates/Buildings
Patient Confidentiality
Theft
Waiting area
Mental Health
Other
If ‘Other’, please specify
Did the Incident Result in Injury/ill Health?
☐
Yes
☐
No
Has the appropriate Manager for the types of
incident/s ticked above been notified?
☐
Yes
☐
No
If ‘Yes’ please specify the name of that Manager
Manager’s name here
Details of Person Injured/Involved
☐ Staff
☐ Patient
☐ Other Medical Staff
☐ Contractor
Name of Person Injured/Involved:
Premises No/Name:
Town:
Click here to enter text.
Premises name/No
Town
Date of Birth:
☐
☐
Other
Occupation/Title: Click here to enter text.
Street:
Street
County
Postcode:
Telephone number:
Insert Telephone Number
County:
Click here to enter a date.
Member of the Public
Postcode
Nature of Injuries
☐
None
☐
Low
Has it been necessary to stop work?
Estimated duration of absence:
☐
☐
Moderate
Yes
Click here to enter duration.
☐
☐
Severe
☐
Death
No
Date last worked:
Click here to enter a date.
Equipment
Type of Equipment:
Type of Equipment.
Model Number:
Model Number
Serial Number:
Serial Number
Batch Number:
Batch Number
Current Location of Equipment:
Location of Equipment
Removed from service?
☐
Yes ☐
No
Violent Incident
Name of Assailant:
Name of Assailant
Premises No/Name:
Premises name/No
Town:
Town
☐
Police Informed?
Yes
PC Shoulder No
PC Shoulder No:
☐
Street
Street:
No
Station:
County
County:
Postcode: Postcode
Name of Officer dealing with
Name of Officer
incident:
Station
Crime No
Crime URN No:
☐
Verbal Abuse
☐
Physical Abuse
☐
Sexual Abuse
☐
Racial Abuse
☐
Drugs Involved
☐
Alcohol Involved
Weapon Involved?
☐
Yes
☐
No
Damage to property?
☐
Yes
☐
No
Type of Incident:
Description of Incident
Initial Report by:
☐ Witness or ☐
Name of witness/staff member:
If ‘Yes’ please specify type
Staff member
Click here to enter text.
Address of witness/staff member:
Type of weapon
Telephone No:
Click here to enter text.
Click here to enter text.
Description of Incident: Please include vehicle registration number if applicable and also actual location
within the building. (Please attach a separate sheet for additional comments. DO NOT write on the back of
these forms)
Click here to enter text.
Risk Rating 1 (tick as appropriate)
Impact
☐ Insignificant (1) ☐ Minor (2)
☐ Unlikely (2)
Likelihood ☐ Rare (1)
☐
Moderate (3)
☐
Major (4)
☐
Catastrophic (5)
☐
Possible (3)
☐
Likely (4)
☐
Almost Certain (5)
Total Risk Score (Impact x Likelihood):
Click here to enter text.
Name:
Click here to enter text.
Date
Click here to enter a date.
Signed
Line Manager Investigation Outcomes And Remedial Actions Taken
Click here to enter text.
Name of Line Manager:
Telephone: Click here to enter a date.
Description of Line Managers investigation of the initial report including any immediate actions taken and
any investigation outcomes.
Click here to enter text.
Risk Rating 2 (rating should be completed as soon as possible after the incident and after
remedial actions undertaken, tick as appropriate)
☐ Moderate (3) ☐ Major (4)
☐ Catastrophic (5)
Impact
☐ Insignificant (1) ☐ Minor (2)
Likelihood
☐
☐
Rare (1)
Unlikely (2)
☐
Possible (3)
☐
Total Risk Score (Impact x Likelihood):
Click here to enter text.
Signed
Date
Likely (4)
☐
Almost Certain (5)
Click here to enter a date.
Does this Incident require escalating to Senior Management?
☐ Yes ☐ No
If ‘Yes’ please fill out the following section…
Senior Management Investigation Outcomes And Remedial Actions Taken
Name of Senior Manager: Click here to enter text.
Telephone: Click here to enter a date.
Description of Senior Management investigation of the incident including any immediate actions taken and
any investigation outcomes.
Click here to enter text.
Risk Rating 3 (rating should be completed after investigation and further remedial actions
by senior management, tick as appropriate)
☐ Moderate (3) ☐ Major (4)
☐ Catastrophic (5)
Impact
☐ Insignificant (1) ☐ Minor (2)
☐ Unlikely (2) ☐ Possible (3)
☐ Likely (4)
☐ Almost Certain (5)
Likelihood ☐ Rare (1)
Total Risk Score (Impact x Likelihood):
Click here to enter text.
Signed
Date
Click here to enter a date.
Feedback to Staff
Description of any feedback to staff regarding the Incident. Please include details of how feedback was
given, who it was given by and who it was given to; also how the feedback was received and any reflections
on the incident.
Click here to enter text.
Name:
Click here to enter text.
Date
Click here to enter a date.
Signed
Root Cause Analysis
RCA to be conducted?
☐ Yes ☐
Supplementary Reporting
CQC
☐
☐
Police
☐
☐
No
RIDDOR
Feature
RCA Conducted?
☐
☐
NPSA
☐ Yes ☐
☐
No
MHRA
Other NHS Bodies
Reviewed by Clincial Governance (QGPS&R)
Name (please print):
Signed
Click here to enter text.
Date
Click here to enter a date.
☐
CFSMS
Additional Comments
Click here to enter text.
Click here to enter text.
Name:
Date
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Signed
EBPCOOH/CG/MB
IR1 Form
Rev 7
8/2012