Critical Incident Report This evaluation form is to be completed following an incident.Incident name:Date of incident: DD slash MM slash YYYY Location of incident:Critical incident team leader:Brief description of incident that occurred1. What action was taken to address the incident, including follow up action?2. Please identify any issues that may have contributed to, or caused the incident3. What steps could be taken to reduce the risk of the incident occurring again?4. Please identify ways in which the response to the incident could be improved.Report completed by :Name & Title :Date DD slash MM slash YYYY SignatureADMIN ONLYImprovements suggested (Q3 & 4)? NAInitial :Date DD slash MM slash YYYY If yes: Added to Feedback Register? NAInitial :Date DD slash MM slash YYYY Added to Feedback Register? NAInitial :Date DD slash MM slash YYYY