QLHF Incident Report
QLHF Incident Report
Group __________________
Name _______________________
Group __________________
Name _______________________
Date _____/______/_______
Time _______________________
Date _____/______/_______
Time _______________________
Situation/ circumstances that led to injury
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Management
_____________________________________________________________
_____________________________________________________________
Witnesses to Incident
_____________________________________________________________
_____________________________________________________________
Situation/ circumstances that led to injury
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Management
_____________________________________________________________
_____________________________________________________________
Witnesses to Incident
_____________________________________________________________
_____________________________________________________________
Site of Injury
Site of Injury
Follow through
_______________________________
_______________________________
_______________________________
_______________________________
Initial Assessment
DRABC ( )
Skin: Colour
Temp
Pale
Normal
____________ or by touch
Dusky
Pulse: Rate
Rhythm
Volume
____________
Regular

Irregular
Normal
Weak 
Bounding
Follow through
_______________________________
_______________________________
_______________________________
_______________________________
Initial Assessment
DRABC ( )
Skin: Colour
Temp
Pale
Normal
____________ or by touch
Dusky
Pulse: Rate
Rhythm
Volume
____________
Regular

Irregular
Normal
Weak 
Bounding
Respiration
Rate
Rhythm
Depth
Quality
Conscience state
Eye opening
Score______
Total__________
Regular
Adequate
Easy
Irregular
Shallow
Labored
Respiration
Rate
Rhythm
Depth
Quality
Conscience state
Eye opening
Score______
Total__________
Deep
Wheezing
Best verbal response Best motor response
____________
__________
Regular
Adequate
Easy
Irregular
Shallow
Labored
Deep
Wheezing
Best verbal response Best motor response
____________
__________
Pupils
Pupils
Reacting Left yes  no Right yes  no
Size ______________
Handgrips
Left weak  strong Right weak  strong
Movement in all limbs
yes  no
Reacting Left yes  no Right yes  no
Size ______________
Handgrips
Left weak  strong Right weak  strong
Movement in all limbs
yes  no
Time
Skin/ Colour
Condition
Temp
Pulse/ Rate
Rhythm
Volume
Respiration
Rhythm
Depth
Quality
Consciousness /
Pupils/ size
Reactive
L
Time
Skin/ Colour
Condition
Temp
Pulse/ Rate
Rhythm
Volume
Respiration
Rhythm
Depth
Quality
Consciousness /
Pupils/ size
Reactive
L
/ /
R
/
L
/ /
R
/
L
/ /
R
/
L
/ /
R
Name of attendant______________________________________________
Signature
______________________________________________
Signature of injured party________________________________________
/ /
R
/
L
/ /
R
/
L
/ /
R
/
L
/ /
R
Name of attendant______________________________________________
Signature
______________________________________________
Signature of injured party________________________________________