Critical Incident Report Form

This form allows staff to document a critical incident that occurred on-site in a structured way, capturing the initial response, root-cause analysis, and corrective actions taken.

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Incident Date/Time

Location (where the incident occurred within the facility)

Staff Member

Nombre

Apellido

Nature of Incident (a brief description of what happened)

Persons Involved (identification of individuals involved, including visitors, staff, and any witnesses)

Impact on Visitor (description of any harm or potential harm to the visitor)

Impact on Staff (description of any harm or potential harm to the staff)

First Response (actions taken immediately after the incident)

Notification (who was notified and when)

Visitor Name

Nombre

Apellido

Date of Birth

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Client Record Number

Accounts from Staff

Accounts from Witnesses

Equipment or Resources Involved

Human Factors

Environmental/System Factors

Root Cause Analysis (RCA)

Investigation Details

Preventive Measures

Corrective Actions

Preventive Actions

Reviewing Staff

Approval

Critical Incident Report Form

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