Incident Report Form

This form should be used to report any incident/accident or potential incident (i.e. a ‘near miss’) which has caused loss, harm or damage, or has the potential to cause loss, harm or damage to any individuals involved, or loss or damage in respect of property/equipment.

Your Details

Your Name (required)

Your Position (required)

Name of Institution (required)

Ward/ Department (required)

Your Email (required)

Your Telephone (required)

Location and Identification

The Incident is About? (required)
 An Arcadia Registered Candidate An Arcadia Client An Arcadia Staff Member

Full Name

Contact Telephone

Job Contact Email

Description of Incident

Brief Description of Incident

Workplace, Care Area of Person or Property Affected/Harmed/Damaged:

Exact Location of Incident (ward, department,room, patient’s home etc)

Date of Incident (required)

Exact Time of Incident (required)

Category of Incident

Medication Related Incident
 Yes No

If the Incident is one of Violence & Aggression):
 Yes No

If Incident is a Missing Patient/Client, please state:

Date Missing

Time Missing

Date Returned

Time Returned

If Returned, Please State How (Police, Own Volition, Staff etc.)

Is this Incident RIDDOR Reportable?
 Yes No

Injury Details

Part of Body Injured (please indicate side where appropriate, i.e. left or right

Nature of Injury (i.e. cut, abrasion, bruise, strain, sprain, fracture, burn, fatality etc)

Treatment received (i.e. first aid, A&E, GP/Doctor, admission to acute hospital etc)

Safeguarding Adults / Children

Is this a Safeguarding Issue relating to an:
 Adult Child

Notification of Incident Made To

If Notification has been nade, please indicate to who
 Police Relative Senior Manager HSE

The personal details given will be held by Arcadia and processed in accordance with the principles of the Data Protection Act 1998 (DPA).

Your details will not be shared with third parties.

Please note that after you press submit you will also receive an email confirming that your form has been successfully submitted. We will send a written acknowledgement of the incident indicating what steps we are taking to address the incident, oversight or omission.