Incident Reporting Form 

 

Incident Reporting Form 

To be completed by Staff reporting Incident : 

INCIDENT DETAILS Ref: 

Today’s date:

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: