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Incident Record Form

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Incident Record Form

To be completed by Lydian managers for any incident/accident/complaint or notifiable event. A copy of this form will be sent to the person reporting the event and to the registered manager.
  • Select from drop down list the type of report you are making.
  • :
  • This is the staff member who reported the incident/event to you to record.
  • This is your details as the person completing the form.
  • Email Address - You will receive a copy of the completed form.
  • The name of the hospital or private site where the incident/accident or complaint occurred within.
  • :
  • Primary Location e.g. service users home (including Address & Postcode if appropriate)
  • Actual location of incident e.g. kitchen, bedroom etc.
  • Outline what happened together with any relevant circumstances. Where applicable, what was the person doing? Were there any contributory factors?
  • Outline the complaint as received.
  • Identify all areas affected
  • If more than one body part is identified above, please identify which injury relates to which body part
  • Type of incident
  • Only choose ‘Yes’ if the equipment involved was linked to the cause of the incident.
  • For example Hoist.
  • Only choose ‘Yes’ if the property involved was linked to the cause of the incident.
  • For example House Key.
  • What action was taken at the time the incident was discovered.
  • Witnesses are only those individuals who saw the incident occurring – not who came across the incident after the event.

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