Incident Report Form | Smile Team Orthodontics

Patient Employee First Aid Incident Close Call Observation

First Name*

Last name *

E-mail*

Date of Birth*

Address*

Date of Event*

Location of Event*

Time of Event*

Witness*

Witness Contact Number*

Describe tasks being performed and sequence of events*

Name

Position

Has an Investigation been carried out? * Yes No

Date

Has a blood test been issued? * Yes No

Date

Was medical treatment necessary? * Yes No

Date

If YES, name of hospital or physician

Details of the Investigation*

Name of Person completing report

Date

Name of Supervisor

Date

Incident Reporting Form