Incident Report Form
This form is to be completed by MS Society employees and volunteers where there is an incident but no one is injured. By reporting at this stage, it may be possible to stop someone being seriously injured in the future.
Please note if an injury has occurred it must be reported on the accident report form.
Details of person involved in the incident
If other connection please detail below
If an employee, please provide their department and building
If a volunteer, please provide their group name
Details of person completing the form
If an employee, please provide the department and building
If a volunteer, please provide the group name
Details of the incident
Location of incident (room, dept, building, vehicle etc):
Did incident occur because the individual was alone?
Details of how the incident occurred with cause if known
List any actions that could be in place to stop this incident occurring again
Please provide full name, full postal address and contact numbers of any witnesses available.
The information enclosed is accurate to the best of my knowledge.
Data provided in this form will be used to review the incident and will be stored in line with the MS Society data retention schedule. The information will be shared with the Health and Safety Executive when required by law.
Please tick the box below and input your email address to receive a copy of the completed form. This should be shared with the person involved in the incident and should then be deleted.
Send me a copy of my responses
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