Incident Reporting Form
To be completed by Staff reporting Incident :
| INCIDENT DETAILS | Ref:
Today’s date: |
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| Incident Date | Incident Time | ||||
| Date reported | |||||
| Discovered By | |||||
| Department | |||||
| Initials of people involved | |||||
| INCIDENT DESCRIPTION |
| Outline the background to the incident |
To be completed by DPO :
| IMPACT OF INCIDENT | |
| Severity of incident/baseline score/whether it needs to be reported
Possible impact and longer term risks identified Root cause and supporting evidence |
|
| Incident level (HSCIC Scoring) | |
| RECOMMENDED ACTIONS / ACTIONS COMPLETED | |
| Key steps taken to manage the incident
Agreed corrective action |
|
| Recommended By: | Date: |
| CONCLUSION | |
| Identify any other areas for improvement and follow up improvement action with target dates for completion of such action | |
| Closed and signed off by: | Date: |