VISITOR INCIDENT / ACCIDENT REPORT FORM Form Code: HSW-F36
HSWAGATA BUDDHA TOOTH RELICS PRESERVATION MUSEUM
VISITOR INCIDENT / ACCIDENT REPORT FORM
Form Code: HSW-F36
Incident Number: __________________________
Date of Report: ____ / ____ / ______
1. BASIC DETAILS
1.1 Date of Incident: ____ / ____ / ______
1.2 Time: __________
1.3 Place (room, hall, stair, outside area):
_________________________________________
2. PERSON INVOLVED (VISITOR)
2.1 Name (if known): ________________________
2.2 Gender: ___________ Age (approx.): _____
2.3 Address / Contact (if given):
_________________________________________
_________________________________________
3. TYPE OF INCIDENT
(tick one or more)
[ ] Fall / slip / trip
[ ] Health problem (faint, chest pain, etc.)
[ ] Accident with object / display
[ ] Aggressive behaviour / argument
[ ] Other: __________________________________
4. DESCRIPTION OF INCIDENT
(What happened? How did it happen?)
______________________________________________
______________________________________________
______________________________________________
5. WITNESSES
(people who saw what happened)
5.1 Witness 1 Name: __________________________
Contact (if known): ______________________
5.2 Witness 2 Name: __________________________
Contact (if known): ______________________
6. ACTION TAKEN
6.1 First Aid Given?
[ ] Yes [ ] No
If yes, by whom and what was done:
_________________________________________
6.2 Was ambulance or doctor called?
[ ] Yes [ ] No
Details: _________________________________
6.3 Was security called?
[ ] Yes [ ] No
Details: _________________________________
7. FOLLOW-UP
7.1 Was the area made safe?
[ ] Yes [ ] No
How? _____________________________________
7.2 Any further action needed?
_________________________________________
_________________________________________
8. REPORTING
Name of Staff Reporting:
_____________________________________________
Role: _______________________________________
Signature: ______________ Date: ____/____/____
Supervisor / Manager Review:
Name: _______________________________________
Signature: ______________ Date: ____/____/____